Bankruptcy Evaluation Form

Bankruptcy Evaluation

Please complete the form below, fields marked with ** are required to process.

  • General Information
  • Income
  • Monthly Expenses
  • Assets
  • Debts
Phone Number: **
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Physical Address: **
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City: ** Invalid Input State: **
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How did you hear about us? ** Please enter how:  
Have you lived at this address the past 3 years? If no, please list the previous addresses and dates of where you lived:
Have you ever filed Bankruptcy before?
If yes:
Will this be a joint filing? :
Employer's Name and Address: How long at this job?
 Occupation Title:
Gross Wages Per Pay Period:
Spouse's Employer's Name and Address:
GrossWages Per Pay Period:
 Net/Bring Home Wages Per Pay Period:
Income from other sources (second job, social security, pension, child support, worker's compensation, etc)
(state source and amount):
Please list your MONTHLY expenses separately, such as:
Rent / Mortgage: Car Payment 1: Cable TV:
Second Mortgage: Car Payment 2: Internet:
Real Estate Taxes: Auto Insurance: Phone:
Electric/Gas: Cell Phone:
Homeowners / Renters Insurance:
Out of Pocket Life Insurance:
Clothing: Out of Pocket Health Insurance:
Charities: Out of Pocket Medical Expenses:
Food: Any other Medical Expenses Other Than Credit Card Debt:
Laundry / Cleaning:
Recreation:
Daycare Expenses: Do you pay anyone child support?
If yes, to whom and how much?

Do you own or are you purchasing a home or other real property?
If yes:
Is this property titled individually or jointly? Stories
Fair Market Value/Last Appraisal: $ Bedrooms
First Mortgage Loan Balance: $ Bathrooms
Is the loan current?
Amount behind: $
Second Mortgage Loan Balance: $
Is the loan current?
Amount behind: $
Are you facing foreclosure?
Forclosure Date:
List Vehicles (Car, Truck, Motorcycle, RV, etc):
Vehicle Description:
Estimated Mileage:
Estimated Fair Market Value: $
Estimated Loan Balance: $
Current Monthly Payments: $
Is the loan current?
Amount behind: $
Is the vehicle currently insured?
Have you had this vehicle for greater than 2.5 years?
List additional Vehicles (Car, Truck, Motorcycle, RV, etc):
Vehicle Description:
Estimated Mileage:
Estimated Fair Market Value: $
Estimated Loan Balance: $
Current Monthly Payments: $
Is the loan current?
Amount behind: $
Is the vehicle currently insured?
Have you had this vehicle for greater than 2.5 years?
List additional Vehicles (Car, Truck, Motorcycle, RV, etc):
Vehicle Description:
Estimated Mileage:
Estimated Fair Market Value: $
Estimated Loan Balance: $
Current Monthly Payments: $
Is the loan current?
Amount behind: $
Is the vehicle currently insured?
Have you had this vehicle for greater than 2.5 years?
Estimate balances owed on all other types of debt listed below:
Medical Bills: $ Credit Cards: $
Have you used your credit cards in the last 90 days? If Yes, How much: $
Tax Debt: $ Personal Loans: $
Cash Advances: $ Student Loans: $
Deficiency Balance Repossed Vehicle: $
Deficiency Balance Sheriff's Sale: $
Are you currently financing any household goods and furnishings?
Financed Through? Amount Financed: $
Have you had this loan for over 1 year?
Have you filed all your tax returns for the last 4 years?
Do you anticipate receiving a tax refund this year?
How much? $
List any Judgments, Liens, or Garnishments against you:
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