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Why are you considering bankruptcy? (select all that apply)
  Garnishment Illness/Disability
  Creditor Harassment License Suspension
  Repossession Divorce
  Foreclosure Loss of Income
  Lawsuits Other:
 
  Estimate Total Debt: $
     

What bills do you have? (select all that apply)
  Credit Cards / Store Cards Income Taxes
  Personal Loans Payday Loans
  Child Support Medical Bills
  Student Loans Other:
  Auto Loans  
   
  Estimate Total Monthly Expenses: $
     

Do you own real estate? Yes   No
If Yes, are you behind in these payments? Yes   No
   
Do you own an automobile? Yes   No
If Yes, are you behind in these payments? Yes   No
   
Do you have any additional assets
worth more than $1000.00?		 Yes   No
If Yes, please describe:
   

What sources of income do you (and your spouse if married) have?
  Employed, Full-time Child Support/Maintenance
  Employed, Part-time Other:
  Social Security I am married and live with my spouse
  Pension/Retirement No Income
 
  Estimate Total Monthly Income: $
     

First Name:
Last:
Home Phone: - -
Work Phone: - -  x
Cell Phone: - -
Email:
Address:
City, State Zip: