Full Name |
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Address |
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Phone |
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Email Address |
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Best time to contact you? |
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What type of bills do you have?
(Check all that apply) |
Credit Cards
Medical Bills
Judgments
Student Loans
Tax Debts
Government Fines
Personal Loans
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Number of bills |
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Amount Owed: |
Under $5,000
$5,000 - $10,000
$10,000 - $15,000
$15,000 - $20,000
$20,000 - $30,000
$30,000 - $40,000
$40,000 - $50,000
Over $50,000
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Approximate value of home: |
$ |
Approximate balance on mortgage: |
$ |
Monthly mortgage payment: |
$ |
Are you up to date on your mortage payments? |
Yes
No |
Are there any other mortgages on this property? |
Yes
No |
Vehicle 1
Year/Make/Model: |
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Approximate Value: |
$ |
Approximate Balance: |
$ |
Monthly Payment: |
$ |
Are your payments up to date? |
Yes
No |
Vehicle 2
Year/Make/Model: |
|
Approximate Value: |
$ |
Approximate Balance: |
$ |
Monthly Payment: |
$ |
Are your payments up to date? |
Yes
No |
Enter any other property of significant value. (For example, if you own a boat, list it here.) |
|
You
Are you employed? |
Yes
No
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How often do you get paid? |
every week
every 2 weeks
twice a month
monthly
|
Net Pay:
(after taxes, medical adn other deductions) |
$ |
What other types of income do you have?
(Check all that apply) |
Disability
Social Security
Pension
Rental Property
Part-time Job
Child Support
Unemployment
Worker's Compensation
|
Spouse(optional)
How often do you get paid? |
every week
every 2 weeks
twice a month
monthly
|
Net Pay:
(after taxes, medical adn other deductions) |
$ |
2+2=? (to avoid automated spam emails) |
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