Pre-bankruptcy application

All fields on the below form are required. If a particular question does not match your circumstances, please fill in the field with "NA."

First name:
Last name:
First name (spouse):
Last name (spouse):
Email address:
 Marital status:
State you live in:
 County:
Home phone:
 Ages:
Number of dependents:
 How did you find about us?
How should we contact you?
 What's a good time?
Please let us know how we can help you:
 

 

Income

  
Monthly net pay (self):
 Monthly net pay (spouse):
Have you ever filed bankruptcy?
 If so when? (Year):
Other income: Child support, Rental, Retirement/Pension, P.T. Seasonal, UC:
Monthly: $
Comments: 

 

Assets or equity
Checking account:
$		 Savings account:
$
Savings bond/Stocks / mutual funds:
$		 401(K)(B):
$
Retirement:
$		 Other assets:
$

 

Home / Property
Home Mobile home Land Rental
Value(s):
 Balance(s) owed:
Housing:
Own Rent		 Mortgage/Rent per month:
$
Delinquent:
Yes  No		 Number months delinquent:

 

Vehicles / Boats / Cycles / Campers
Year:
 Make:
 Monthly payment:
 Balance owed:
Year:
 Make:
 Monthly payment:
 Balance owed:

 

Monthly payments for unsecured debts
Creditor 1:
 Balance:
 Mo payment:
 Interest rate:
Creditor 2:
 Balance:
 Mo payment:
 Interest rate:
Creditor 3:
 Balance:
 Mo payment:
 Interest rate:
Creditor 4:
 Balance:
 Mo payment:
 Interest rate:
Creditor 5:
 Balance:
 Mo payment:
 Interest rate:
Creditor 6:
 Balance:
 Mo payment:
 Interest rate:
Creditor 7:
 Balance:
 Mo payment:
 Interest rate:
Creditor 8:
 Balance:
 Mo payment:
 Interest rate:
Creditor 9:
 Balance:
 Mo payment:
 Interest rate:
Creditor 10:
 Balance:
 Mo payment:
 Interest rate:

 

Monthly living expenses

Condo fees/Park rent:
 H20 softener/Drinking:
Utilities:
 Cell phone/Pager:
Water/Sewer/Garbage:
 Renter's/Homeowner's insurance:
Home repair/Maintenance:
 Cable TV/Dish:
Video rentals/CDs/Music/DVDs:
 Online computer access:
Food/Groceries/Supplies:
 Meals out:
Gas/Public transportation:
 Auto insurance:
Auto repair/Maintenance:
 Auto registration:
Parking:
 Maintenance/Child support:
Day care/Babysitting:
 Baby supplies:
School expenses/Tuition:
 Child allowance:
Clothing:
 Laundry & dry cleaning:
Personal care:
 Occupational/proff expenses:
Medical/Disability ins./Copay:
 Prescriptions/Medical care:
Life insurance:
 Donations:
Bank fees:
 Gifts:
Pet care:
 Cigarettes:
Alcohol:
 Entertainment:
Newspapers/Magazines/Books:
 Bingo/Casino/Lottery:
Vacation/Trips:
 Savings:
Other periodic expenses:

 

  

 

 

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