Bankruptcy Questionnaire

Thank you for completing the following form. We realize the information asked for is confidential but in order for our firm to give you the best recommendation for your particular situation, please complete the form fully and accurately. If you do not know exact figures, please complete the blank with your best estimate. Please bring to your appointment any lawsuit you have been served with, correspondence concerning any foreclosure, IRS letters, or anything else you feel is important for the attorney to review. Additionally, bring along a recent pay stub for each wage earner in the family.

How Did You Hear About Our Team?

Your Maiden's Name [if applicable]

Your Social Security Number [SSN] *

Marital Status

Spouse's Name [if applicable]

Spouse's Maiden Name [if applicable]

Spouse's Date of Birth

Home Telephone Number *

Mobile/Cell Phone Number

Any Children Living at Home? *

Current Employer(s) *

Length of Employment *

Employer(s) Telephone Number *

Spouse's Current Employer [if applicable]

Spouse's Length of Employment

Spouse's Employer Telephone Number

Do You Own Your House or Do You Rent? *

Rent

Owned

If You Own It, Have You Lived In It For At Least 3 to 5 Years? *

Yes

Have You Lived in Texas for At Least Two (2) Years? *

Yes

Have You Received Any Income Other than Your Job in the Last 6 Mos? *

Yes

If Yes, what income?

Have You Ever Filed for Bankruptcy? *

Yes

If Yes, When Did You File?

Are You Behind in Your House or Rent Payments? *

Yes

If You Are Behind, How Much?

Do You Owe the IRS? *

Yes

If You Owe the IRS, How Much?

Do You Owe State Taxes? *

Yes

If You Owe State Taxes, How Much?

Do You Owe Property Taxes? *

Yes

If You Owe Property Taxes, How Much?

Do You Owe Student Loans? *

Yes

If You Owe Student Loans, How Much?

Are You Behind in Child or Spousal Support? *

Yes

Do You Have Any Insufficient Funds Checks Outstanding? *

Yes

If You Have Any NSF Checks Outstanding, How Much?

Do You Have Any Co-Signers on Any of Your Debts? *

Yes

Have You Co-Signed on Any Debts for Someone Else?

Yes

Whom Have You Co-Signed for Any Debts?

1. Mortgage Company For Home Loans or Land for Mobile Homes *

1. Monthly Payment to Mortgage Company for Home Loans or Land for Mobile Homes

1. Interest Rate for Home Loans or Land for Mobile Homes (Percentage)

% Percentage

1. Balance Due for Home Loans or Land for Mobile Homes

1. Amount Behind for Home Loans or Land for Mobile Homes

1. Value for Home Loans or Land for Mobile Homes

2. Mortgage Company For Home Loans or Land for Mobile Homes

2. Monthly Payment Amount for Home Loans or Land for Mobile Homes

2. Interest Rate for Home Loans or Land for Mobile Homes (Percentage)

Percentage %

2. Balance Due for Home Loans or Land for Mobile Homes

2. Amount Behind for Home Loans or Land for Mobile Homes

2. Value for Home Loans or Land for Mobile Homes

1. Vehicle Make (i.e. Ford) *

List All Vehicles You Own Whether There is a Debt Against Them or Not. If More Than Two Vehicles [Not Including One Recreational] Then Bring Information at Initial Meeting

1. Vehicle Model (i.e. Taurus) *

List All Vehicles You Own Whether There is a Debt Against Them or Not. If More Than Two Vehicles [Not Including One Recreational] Then Bring Information at Initial Meeting

1. Vehicle Year Made *

N/A if Not Applicable

Do You Owe On This Vehicle? *

Yes

If You Owe On This Vehicle, Name of the Lender

1. Payoff Amount on the Vehicle Listed *

1. Value of the Vehicle Listed *

1. Monthly Payment of the Vehicle Listed *

1. Number of Payments Behind *

1. Number of Payments Left *

1. Recreation Vehicle Make *

List All Vehicles You Own Whether There is a Debt Against Them or Not.

1. Recreation Vehicle Model *

1. Recreation Vehicle Year Made *

N/A if Not Applicable

1. Do You Owe on This Recreational Vehicle? *

Yes

1. If You Owe This Recreational Vehicle, Name of Lender

1. Payoff Amount on the Recreational Vehicle Listed Above *

1. Value of the Recreational Vehicle Listed Above *

1. Monthly Payment of the Recreational Vehicie Listed *

1. Number of Payments Behind on Recreational Vehicle *

1. Number of Payments Left on Recreational Vehicle *

1. Name of Creditor for Purchase of Furniture, Appliances, Stereo, etc or Loans for Which You Have Pledged Household Items as Collateral *

If more than two creditors for which you have pledged household items as collateral, bring information to initial meeting. N/A if Not Applicable

1. Collateral on Loan *

N/A if Not Applicable

1. Balance Due on Loan *

1. Number of Payments Behind on Loan *

1. Number of Payments Left on Loan *

1. Name of Creditor

LIST ALL DEBTS EVEN IF YOU DISPUTE THEM OR THEY MAY HAVE BEEN "WRITTEN OFF" BY THE CREDITOR, INCLUDING CREDIT CARDS, MEDICAL DEBTS, PERSONAL LOANS, BAD CHECKS, ETC.

1. Monthly Payment Amount

Are Your Wages Being Garnished or Are They About to be Garnished? *

Yes

Details of Garnishment:

Do You Have Any Judgements Against You? *

Yes

Details of Judgements

Do You Have Any Lawsuits Against You Pending Now? *

Yes

Details of Any Lawsuits:

Do You Have Any Lots, Land or Real Property Other Than The House You Live Now? *

Yes

Details of Any Lots, Land or Real Property Other Than The House You Live In Now

Is Any Creditor Taking Any Deduction Out of Your Paycheck for Loans, Car Payments, etc.? *

Yes

Details of Any Deductions Take Out of Paycheck

Do You Have Over $500 In Savings Accounts, CD's, Stocks, Bonds, or Similar Financial Accounts? *

Yes

If so, Please Describe and List Dollar Value Amounts:

Are You Self-Employed? *

Yes

Details of Your Self-Employment

Are You Currently in the Process of Getting a Divorce or Are You Separated from You Spouse? *

Yes

Details of Divorce or Separation from Spouse

Have You Been Divorced in the Past 10 Years One or More Times? *

Yes

Details of Divorce from the Last 10 Yrs or More:

Have You Made Any Large Purchases Within the Last Three (3) Months on Credit? *

Yes

What Type of Case: *Select One