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Bankruptcy Evaluation Form
Please answer as many of the following questions as you can.
Full Name
Address
Phone
Email Address
Best time to contact you?
What type of bills do you have?
(Check all that apply)
Credit Cards
Medical Bills
Judgments
Student Loans
Tax Debts
Government Fines
Personal Loans
Number of bills
Amount Owed:
Under $5,000
$5,000 - $10,000
$10,000 - $15,000
$15,000 - $20,000
$20,000 - $30,000
$30,000 - $40,000
$40,000 - $50,000
Over $50,000
Approximate value of home:
$
Approximate balance on mortgage:
$
Monthly mortgage payment:
$
Are you up to date on your mortage payments?
Yes
No
Are there any other mortgages on this property?
Yes
No
Vehicle 1
Year/Make/Model:
Approximate Value:
$
Approximate Balance:
$
Monthly Payment:
$
Are your payments up to date?
Yes
No
Vehicle 2
Year/Make/Model:
Approximate Value:
$
Approximate Balance:
$
Monthly Payment:
$
Are your payments up to date?
Yes
No
Enter any other property of significant value.
(For example, if you own a boat, list it here.)
You
Are you employed?
Yes
No
How often do you get paid?
every week
every 2 weeks
twice a month
monthly
Net Pay:
(after taxes, medical adn other deductions)
$
What other types of income do you have?
(Check all that apply)
Disability
Social Security
Pension
Rental Property
Part-time Job
Child Support
Unemployment
Worker's Compensation
Spouse
(optional)
How often do you get paid?
every week
every 2 weeks
twice a month
monthly
Net Pay:
(after taxes, medical and other deductions)
$
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Prior Client
Other
MESSAGE:
Long Island Bankruptcy Attorneys
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We are a qualified debt relief agency. This is Attorney Advertising. The information on this Long Island Bankruptcy Attorneys / Law Firm website is for general information purposes only. Nothing on this or associated pages should be taken as legal advice for any individual case or situation. This information on this website is not intended to create, and receipt or viewing of this information does not constitute, an attorney-client relationship.
Address: 1737 N. Ocean Ave | Medford, Long Island | New York | Telephone: (888) 229-0413