Email:

Filing Jointly

or Filing Separately

Last Name:

First Name:

Middle Name:

Any Other Name(s) Used: (i.e. Maiden name):

Address:

Mailing Address (if different than home address):

Length at Residence

Prior address of debtor :

Home Telephone Number (#)

Work Telephone Number(s) :

Cellular Number(s)

Any Additional Number(s)

Marital Status:

Married Since:

Social Security Number

Date of Birth:

Work Telephone Number(s) :

Last Name:

First Name:

Middle Name:

Any Other Name(s) Used: (i.e. Maiden name):

Address:

Mailing Address:

Social Security Number:

Date of Birth:

Employer’s Name:

Position:

Employer’s Address:

Employer’s Phone Number:

How Long with this Employer?

How often do you get paid?

Estimated Net Income:

Any other source of income? YesNo
If yes, please provide source of Income information:

Employer’s Name:

Position:

Employer’s Address:

Employer’s Phone Number

How long with this employer? :

How often do you get paid?

Estimated Net Income:

Any other source of income? YesNo
If yes, please provide source of income information:

ARE THERE ANY PRIOR BANKRUPTCIES? YesNo
If yes, please provide when & where case(s) was filed, case number(s) and outcome/status of case(s):

Do you have any Real Property? YesNo
If yes, please provide the following information:

Do you wish to surrender home or keep home?

First Mortgage:

Acct. #:

Phone #:

Total loan payoff:

Address:

City:

State:

ZIP:

Monthly payment:

How many months behind are you?:

What happened:

When did you take mortgage out:

When did you buy property:

Address of property:

Is this your residence?

In whose name is loan?

Co-signers?

Who is this person:

How much is property worth in a quick sale?

Has foreclosure started?

Who is foreclosure attorney?

Second Mortgage:

Acct. #:

Phone #:

Total loan payoff:

Address:

City:

State:

ZIP:

Monthly payment:

How many months behind are you?:

What happened:

When did you take mortgage out:

When did you buy property:

Address of property:

Is this your residence?

In whose name is loan?

Co-signers?

Who is this person:

How much is property worth in a quick sale?

Has foreclosure started?

Who is foreclosure attorney?

Make & Model

Year & Value

Mileage

Purchase Date

Monthly Payment

Balance

Condition

Automatic

1.

YesNo

2.

YesNo

3.

YesNo

Date:

Description of property

Value

1.

Cash on hand:

2.

Checking, Savings, etc:

3.

Security Deposits w/landlords, public utilities, etc.

4.

Household goods and furnishings:

5.

Books, pictures, art objects, collectibles:

6.

Wearing Apparel:

7.

Furs and Jewelry:

8.

Firearms, sports, hobby equipment:

9.

Interest in insurance policies:

10.

Annuities:

11.

Interest in IRA or other pension or profit sharing plans:

12.

Stocks, bonds:

13.

Interest in partnership or joint ventures:

14.

Government or corporate bonds:

15.

Accounts Receivables:

16.

Alimony, Maintenance, Support and property settlements in which the debtor may be entitled:

17.

Other liquidated debts owing debtor including tax refunds:

18.

Equitable of future interests other than these listed in Schedule or Real Property:

19.

Contingent and non-contingent interests…

20.

Other contingent and unliquidated claims…

21.

Patents, copyrights:

22.

Licenses, franchised, etc.

23.

Automobiles, trucks, trailers and other vehicle and accessories:

24.

Boats, motors and accessories:

25.

Aircrafts and accessories:

26.

Office equipment, furnishings and supplies:

27.

Machinery, fixtures, equipment and supplies used in business:

28.

Inventory:

29.

Animals:

30.

Crops growing or harvested:

31.

Farming equipment:

32.

Farm Supplies:

33.

Other personal property:

Do you have any executory contracts or unexpired leases of real or personal property?YesNo
If yes, include any timeshare interests, state nature of debtor’s interest in contract and provide names and complete addresses:

Are there any other co-debtors on any of your debts, other than a spouse if joint case? YesNo
If yes, please list names and relationship:

Complete Name(s) of Dependent(s):

Age(s):

Relationship(s):

1.

2.

3.

Rent or Mortgage:

Are property taxes and insurance included? YesNo

Income from employment or business:

Income other than from employment or operation of business:

Payments to creditors:

Suits & administrative proceedings, executions, garnishments and attachments (describe):

Repossessions, foreclosures and returns:

Assignments and receiverships:

Gifts:

Losses:

Payments related to debt counseling or bankruptcy:

Other transfers:

Closed financial accounts:

Safe deposit boxes:

Setoffs:

Property held for another person:

Prior Address of Debtor:

Spouses and Former spouses:

Environmental information:

Nature, location and name of business:

Do you wish to surrender any real or personal property? YesNo
If yes, please describe which real/personal property you intend to surrender:

Have you had any real property foreclosed? YesNo
If yes, please list real property address and date of foreclosure:

Have you had any vehicle(s) repossessed? YesNo
If yes, please list vehicle information and date of repossession:

Have you used any credit cards or taken any cash advances out in the last 6 months:YesNo
If yes, please list detailed information regarding activities:

Previous 2 counties that you have lived in:

Previous 2 employers:

Previous 2 phone numbers:

Name and amount of previous 2 Banks that you may have obtained a Mortgage from:

Date Submitted:

Electronic Signatures: