Date:
* Last:
First:
Middle:
* Email Address:
Spouse Last:
Spouse First:
Spouse Middle:
Street Address:
City:
County:
State:
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Zip:
Home Telephone:
Business Telephone:
Cell Telephone:
Other Telephone:
Marital Status:
How did you hear about the office:
Have either you or your spouse ever filed for bankruptcy before?
If yes, disclose all prior bankruptcies and when and where filed
County:
Chapter 7:
Chapter 13:
Year:
Result:
Brief your reasons for coming in to see us today:
REAL PROPERTY - Please Check The Appropriate Answers Below:
Are you:
Fair Market Value:
Pay Off Amount:
Monthly Payment:
Mortgage company, if any:
Due On:
Are you:
If you are delinquent, how many months?
Includes which months?
Have you received a foreclosure notice?
If Yes, when is your foreclosure date?
Name, address and phone # of foreclosure attorney:
Do you have an escrow account?
If no, do you have any property taxes unpaid?
Have you lived in Texas for the last 4 years?
Do you own any other REAL ESTATE, BOATS, LAND PARCELS, TIMESHARES, etc.?
VEHICLES - Please list all the vehicles you own, are financing or have co-signed for:
Make/Model:
Year:
Finance Co.:
Lease or purchase:
Mileage:
Amount owed:
Monthly Payment:
Are you current:
If no, how many months behind?
Date of Purchase?
Payment Due Date:
Make/Model:
Year:
Finance Co.:
Lease or purchase:
Mileage:
Amount owed:
Monthly Payment:
Are you current:
If no, how many months behind?
Date of Purchase?
Payment Due Date:
What type of insurance do you have on these vehicles?
(For Example: full coverage insurance for financed vehicles)
If you have more than 2 vehicles, please list below and check this box yes, I have more than 2 vehicles:
Please list vehicles if you have more than 2:
Do you ove any taxes to the IRS?
If yes, which year(s) and how much do you owe by year?
Has a tax lien been files?
Do you owe any other taxes?
If yes, describe:
Have you filed your tax returns for the past six (6) years?
If no, please explain:
Do you have any loans in which they made you list items you already owned?
In the last 90 days, have you had over $500.00 in debt to a single creditor for luxury goods or services?
Any cash advances more than $750.00 within the last 70 days?
Have you paid off any creditor or made any payments over 500.00 (in one month to any creditor in the last 180 days?
Have you had any repossessions or foreclosures before?
If yes, balance owed:
If yes, describe the property, state the year and the creditor:
Do you have student loans or are you the guarantor for someone else's student loans?
If yes: Balance on Loan
If yes: Monthly Payment
If yes: Lender
Have you sold, transferred or given away any personal or real property in the last 10 years? If yes, please describe the transaction below:
Within the last ten years, have you sold or transferred any property and invested proceeds in your home:
If yes, please explain:
Are there any lawsuits pending against you or are you currently suing someone or have the right to sue someone for money damages (e.g. personal injury suit, wrongful termination, car accident, etc.)
If yes, please describe below:
Have you ever been sued before?
If yes, please describe:
Other Assets:
Stocks or Bonds:
Describe:
Value:
IRA, 401k, Retirement, etc.:
Describe:
Value:
Do you have a loan from your retirement account?
If yes, balance:
Monthly payment amount:
Are you making voluntary contributions to your retirement accounts?
If yes, amount per month:
Other Valuable property:
Describe:
Value:
Describe:
Value:
Checking Account Balance:
Savings Account Balance:
Other Financial Account(s) Cash Balance:
Do you have a loan with the credit union?
If yes, balance?
Do you owe money to any institution where you have money there?
If yes, where?
Do you have a pending interest in an estate or do you expect to inherit any money in the next 6 months?
If yes, please explain:
Do you have any property interests in any other property where you area co-owner or co-debtor?
If yes, please explain:
Have you co-signed for any accounts or are an authorized user of any other accounts?
If yes, please explain:
Income
Employer:
How do you get paid:
Your monthly gross income:
Deductions on payroll check:
Your net monthly income:
Spouse's employer:
How do you get paid:
Your monthly gross income:
Deductions on payroll check:
Your netmonthly income:
Total monthly expenses:
Money left over after deducting monthly expenses:
Number of people in your household:
(This includes you and your spose and anyone else that you claim as a dependent on your tax return)
Are you behind on child support?
If yes, balance owed:
Are you court ordered to pay child-support?
If yes, monthly amount:
Do you have any children 18 years or under living in your household:
Do you have any life insurance policies:
If Yes, monthly amount:
Do you have any childcare expensies:
If Yes, monthly amount:
Do you have any healthcare expenses not already taken from your check?
If Yes, monthly amount:
Do you make any monthly charitable contributions:
If Yes, monthly amount:
Any other expenses that have not neen listed that we should know about:
Bankruptcy Chapter 7