First Name

Middle Initial

Last name

Have you ever filed bankruptcy before?

If yes, what type?

You are married? You are married?--YesNo

City

State

City

State

Home Phone Number (xxx) xxx-xxxxx

Cell Phone Number (xxx) xxx-xxxxx

Email

First name

Middle Initial

Last name

Have you ever filed bankruptcy before?

If yes, what type?

When?

Foreclosure?

Payday Loans?

Repossession?

Driver License Suspension?

House Sale?

Judgments?

Garnishment?

Medical Bills?

Credit Card Debt?

Other?

Do you own any real estate? Do you own any real estate?YesNo

1. Address:

2. Approximate current market value? $

3. Amount owed on first mortgage?

Monthly Payment? $

4. Amount owed on second mortgage?

Monthly Payment? $

5. Are you behind on any of your mortgage payments? 5. Are you behind on any of your mortgage payments?YesNo

I am approximately

I am approximately

6. Is anyone else on the deed to this property? 6. Is anyone else on the deed to this property?NoYes

If yes, who?

1. Address:

2. Approximate current market value? $

3. Amount owed on first mortgage?

Monthly Payment? $

4. Amount owed on second mortgage?

Monthly Payment? $

5. Are you behind on any of your mortgage payments? 5. Are you behind on any of your mortgage payments?YesNo

I am approximately

I am approximately

6. Is anyone else on the deed to this property? 6. Is anyone else on the deed to this property?NoYes

If yes, who?

Do you have any dependants? Do you have any dependants?NoYes

son(s)/daughter(s)

age(s)

son(s)/daughter(s)

age(s)

”Year”

Make

Model

Style

Mileage

Are you current on payments for this vehicle?

Do you wish to retain this vehicle?

How much is owed on this vehicle?

When did you purchase this vehicle?

If yes: full coverage or liability coverage?

Year

Make

Model

Style

Mileage

Are you current on payments for this vehicle?

Do you wish to retain this vehicle?

How much is owed on this vehicle?

When did you purchase this vehicle?

If yes: full coverage or liability coverage?

Year

Make

Model

Style

Mileage

Are you current on payments for this vehicle?

Do you wish to retain this vehicle?

How much is owed on this vehicle?

When did you purchase this vehicle?

If yes: full coverage or liability coverage?

1. Do you have over $4,000.00 dollars available in cash?

Does your landlord or utility company hold a security deposit? Does your landlord or utility company hold a security deposit?NoYes

Who?

Amount?

3. Approximate resale value (garage sale value) of all your household goods and furnishings? $

4. Approximate resale value (garage sale value) of all of your collectible items? (i.e. art work, books, CDs, etc) $

5. Approximate resale value (garage sale value) of all your clothing and accessory items? (furs diamonds, etc.) $

6. Do you own Firearms or Sporting Goods? 6. Do you own Firearms or Sporting Goods? NoYes

Approximate value: $

7. Do you have a life insurance policy? 7. Do you have a life insurance policy?NoYes

a. Whole-life insurance or term-life insurance?

If yes, up to how much can you borrow? $

8. Do you own any stocks, bonds, annuities, or CDs? 8. Do you own any stocks, bonds, annuities, or CDs? NoYes

Approximate value? $

a. I have a Pension with my employer? $

b. I have a 401(k)? $

with an approximate value of $

10. Do you have an interest in any business, patent, license, copyright, corporation, or partnership? 10. Do you have an interest in any business, patent, license, copyright, corporation, or partnership?NoYes

Please explain:

11. Does anyone owe you any money over $500.00? 11. Does anyone owe you any money over $500.00?NoYes

Please explain:

12. Do you have the right to sue anyone for any reason? 12. Do you have the right to sue anyone for any reason?NoYes

Please explain:

13. Do you anticipate an inheritance for any reason in the immediate future? 13. Do you anticipate an inheritance for any reason in the immediate future?NoYes

14. Do you own any boats, trailers, snowmobiles or other motorized equipment? 14. Do you own any boats, trailers, snowmobiles or other motorized equipment?NoYes

Please explain:

15. Are you owed any amounts of money? (i.e. tax refunds, back-pay settlements, back disability, social-security benefits, or pension settlements) 15. Are you owed any amounts of money? (i.e. tax refunds, back-pay settlements, back disability, social-security benefits, or pension settlements)NoYes

Please explain:

Rent: $

Mortgage: (1st) $

Mortgage: (2nd) $

Mortgage: (3rd) $

Utilities (gas/electricity) $

Water/sewer: $

Phone: $

Food: $

Gasoline: $

Bus/Train: $

Auto Insurance: $

Alimony/child support: $

Car payment 1: $

Car Payment 2: $

Student Loan: $

Life Insurance: $

1. How often do you get paid?

Average Paycheck Amount? : $

a. Gross Wages: $

b. Net Wages: $

2. If married, how often does your spouse get paid?

3. Average Paycheck Amount? : $

a. Gross Wages (per paycheck): $

b. Net Wages (per paycheck): $

a. Social security benefits?

If yes, how much? $

b. Unemployment benefits?

If yes, how much? $

c. Pension/Retirement?

If yes, how much? $

d. Disability?

If yes, how much? $

e. Workmen’s Compensation?

If yes, how much? $

f. Rental Income?

If yes, how much? $

g. Child Support?

If yes, how much? $

h. Other?

If yes, how much?

1. Do you owe any money to State- or Federal-Tax Agencies? 1. Do you owe any money to State- or Federal-Tax Agencies?NoYes

Please explain:

2. Do you owe child support? 2. Do you owe child support?NoYes

Please explain:

3. In the last three months, have you made a payment to any creditor (excluding mortgage payments) in an amount greater than $500.00 dollars? 3. In the last three months, have you made a payment to any creditor (excluding mortgage payments) in an amount greater than $500.00 dollars?NoYes

Please explain:

4. In the last year have you been a party to any law suites? 4. In the last year have you been a party to any law suites?NoYes

Please explain:

5. In the two years, have you transferred any property (either by sale, deed-in-lieu, or foreclosure). 5. In the two years, have you transferred any property (either by sale, deed-in-lieu, or foreclosure).NoYes

Please explain:

6. In the last year, have you experience any losses? (gambling, fire, flood, theft) 6. In the last year, have you experience any losses? (gambling, fire, flood, theft)NoYes

Please explain:

7. In the last year, have you given, sold or transferred anything worth more than $1,000.00 dollars? 7. In the last year, have you given, sold or transferred anything worth more than $1,000.00 dollars?NoYes

Please explain:

8. Do you have a safety-deposit box? 8. Do you have a safety-deposit box?NoYes

9. In the last 2 years have you lived in any state other than Illinois? 9. In the last 2 years have you lived in any state other than Illinois?NoYes

Please explain:

10. In the last 6 years, have you owned, operated, managed, or participated in any business, corporation, L.L.C. or partnership? 10. In the last 6 years, have you owned, operated, managed, or participated in any business, corporation, L.L.C. or partnership?NoYes

Please explain:

11. Do you currently use, maintain, hold or control any property or money that belongs to someone else? 11. Do you currently use, maintain, hold or control any property or money that belongs to someone else?NoYes

Please explain: