Free Case Evaluation

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Name
First Last
Address
Street Address City ZIP Code
Phone
Email
Best time to reach you:
Preferred appointment time:
Preferred appointment location:
Bankruptcy is for:
Debts:
Check all of the following for which you owe money and estimate the total dollar amount owed for each debt.
Credit Cards $
Medical Bills $
Personal Loans $
Student Loans $
Vehicle Loans $
Judgements/Lawsuits $
Broken Lease Contracts $
Accident Claims Against You $
Owed Taxes $
Real State and Home Mortgage:
Check all of the following for which you OWE MONEY and estimate the total dollar amount owed for each debt.
Do you currently own a home?
- Yes
- No
Market Value $
Pay Off Amount $
Months Behind:
Assets:
Check all that apply to you and estimate their value.
Artworks $
Electronics/Computers $
Furniture $
Jewelry $
Vehicles/Boats
Stocks $
Income:
Check all that apply to you and estimate their value.
Gross Monthly Income $
Net Income $
Spouse Gross Income $
Spouse Net Income $
Rental Income $
Retirement or Pension $
Social Security or Disability $
Expenses:
Check all that apply to you and estimate their value.
Mortgage/Rent $
Medical/Prescriptions $
Utilities $
Health Insurance/Dental $
Cable TV $
Telephone/Cellular $
Child Care $
Maintenance $
Children School Expenses $
Home Repairs $
Entertainment $
Food $
Haircuts/Toiletries $
Car Payments $
Pets $
Car Insurance $
Property Taxes/Insurance $
Gas/Car Maintenance/Toll $
Additional Information:
Any other information we should know:

Debts: