Why are you considering bankruptcy?

Garnishment

Lawsuit

Credit Debt

Divorce

Medical (Illness / Injury)

Job loss

Business failure

Repossession

Other

What bills do you have? (Check all that apply)

Credit cards

Medical related bills

Past due auto payments

Past due mortgage payments

Business loans

Personal loans

Child support

Student loans

Separate maintenance

Judgments

What is your total credit card debt, if any?:

What is your total debt in regards to personal loans, if any?:

What is your total medical related debt, if any?:

What is your total debt in regards to business loans, if any?:

What is your total debt in regards to judgments, if any?:

Do you currently own a house?

Yes

No

Are you behind on your mortgage payments?

I own my home free and clear Current on payments Behind 1 month on payments Behind 2 months on payments Behind 3 months on payments Behind 4 months or more

What is your monthly mortgage payment?:

What other assets do you own? (Check all that apply)

Second home

Vacation home / property

Timeshare

Commercial property

Rental properties

Land - Property

Motorcycle

Boat

Other

Recreational vehicle

What is your current GROSS monthly income? (Before taxes and benefits are taken out):

If applicable, what is your spouses current GROSS monthly income?:

Other Comments:

Name:

Email Address:*

Phone number:

What is the best time to call?: