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Confidential
Client Questionnaire Please complete all pages. This information will not be shared with
anyone. |
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Your Name: |
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Spouse’s Name: |
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Address: |
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City: State: Zip: County: |
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Phone: Email: |
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Marital Status: |
□ Married □ Divorced If divorced, in what year? _______ □ Single □ Separated |
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Are you currently involved, or do you expect to be involved in a divorce, dissolution, or legal separation? |
□ Yes □ No |
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Have you filed any bankruptcies in the past? |
□ Yes □ No |
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If yes, what chapter? |
□ 7 □ 13 In what year? |
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Have you seen any other attorneys regarding your debt in the last year? |
□ Yes □ No |
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If yes, which attorney(s) did you see? |
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Please tell us
how you heard about West & Associates Check all that apply |
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□ TV Commercial – Cable □ TV Commercial – Channel 7 □ Website (DebtFreeOhio.com or RichardWestAttorney.com) □ SBC Yellow Pages - □ SBC Yellow Pages – □ Yellow Book Yellow Pages - □ Yellow Book Yellow Pages - Butler/Warren |
□ Newspaper - □ Newspaper - □ Mailer from our office □ □ Referral (who referred you): _____________ □ Other (please explain): _________________ |
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What caused you to fall behind on your bills? |
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Debt
Information Tell us how much you owe for each category – estimate if
unsure of amount. |
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Real Estate: |
Credit Cards: |
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Vehicle: |
Medical Bills: |
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Taxes: |
Pay Day Loans: |
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Secured Loans: |
Unsecured loans: |
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Other (secured): |
Other (unsecured): |
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Student Loans: |
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(Secured means you pledged property to secure the debt) |
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Which debts are paid current as of this month? |
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Which debts are you currently behind on? |
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Mortgage
Information If you own property – if you rent skip to next section |
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How much would your house sell for “as is” today? |
$ |
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What is your mortgage payoff amount? |
$ |
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Second mortgage payoff amount? |
$ |
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Third mortgage payoff amount? |
$ |
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If you have more than one house in your name, check here □ |
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Does your mortgage payment include taxes and insurance? |
□ Yes □ No |
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If no, how much are your Real Estate Taxes per half? If no, how much is your Homeowner’s insurance per year? |
$ ÷ 6= ______________ $ ÷ 12= _____________ Total monthly housing cost =____________ |
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□ Check here if your house is a Condominium or if you owe Homeowners Association Fees |
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Has your mortgage been sold or transferred since you bought the property? □ Yes □ No |
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Housing Expenses
(If you Rent) |
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Rent amount per month? |
$ |
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Household
Members & Dependent Information |
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Below, please list all of your dependents, even if
they do not live with you and household members even if not dependent. If you pay or receive support, please indicate the amount and whether you pay or receive that amount. |
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Dependents you
support: |
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Name |
Age |
Relationship |
Pay or Receive Support? |
Amount of Monthly Support Paid or Received? |
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□ Pay □ Receive |
$ |
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□ Pay □ Receive |
$ |
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□ Pay □ Receive |
$ |
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□ Pay □ Receive |
$ |
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□ Pay □ Receive |
$ |
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□ Pay □ Receive |
$ |
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If you pay child support, are you current on your payments? |
□ Yes □ No |
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If you are behind, how much do you owe? |
$ |
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Household Members (i.e. Live-in parents, who are not dependants but live with you): |
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Name |
Age |
Relationship |
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Employment Income |
Your Income |
Spouse’s Income |
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Job Title: |
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Employer: |
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Length of time employed there: |
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How often are you paid? |
□ Weekly □ Every 2 Weeks □ Monthly □ 2x /month |
□ Weekly □ Every 2 Weeks □ Monthly □ 2x /month |
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Gross Pay per paycheck: |
$ |
$ |
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Estimated Overtime per paycheck: |
$ |
$ |
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Average monthly commission income: |
$ |
$ |
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Net (take home) Pay per paycheck: |
$ |
$ |
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Other Income |
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Business, Profession, or Farm: |
$ |
$ |
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Real Property: |
$ |
$ |
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Pension and Retirement: |
$ |
$ |
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Alimony or Child Support Received: |
$ |
$ |
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Social Security: |
$ |
$ |
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Other Government Assistance: Please explain: |
$ _________________________ |
$ __________________________ |
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Other Income from any source: Please explain: |
$ _________________________ |
$ __________________________ |
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Has your other income been the same each month for the last six months? If no, please explain why: |
□ Yes □ No _________________________ |
□ Yes □ No __________________________ |
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Other Financial
Information |
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Do you own any
other vehicles, trailers, boats, etc. not listed on your vehicle checklist? If yes, please list them, even if
you do not owe any money for them: |
□ Yes □ No |
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Are your wages or bank account being garnished to pay a
debt If yes, for what debt(s): |
□ Yes □ No |
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Has any property
you have ever owned been repossessed in the last ten years? If yes, list the repossessed
property and the date it was repossessed:
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□ Yes □ No |
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Have you paid any
money to any relatives in the last four years? If yes, please list the date and the
amount of each payment: |
□ Yes □ No |
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Do you owe any
money to a credit union (credit union credit card, loan, etc.)? If yes, is the credit union debt: □ Secured □ Unsecured |
□ Yes □ No |
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Have you used any
of your credit cards in the last 60 days? If yes, list how much have you spent in the last 60 days: $ |
□ Yes □ No |
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Are you currently
purchasing any property on an installment contract? This would include
jewelry, computer, TV, furniture, appliances, purchased on a credit card or
installment contract. If yes, please
list what was purchased, when purchased and how much you still owe: |
□ Yes □ No |
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Do you have any
property worth more than $400 (quick sale value)? This includes bank
accounts, stocks, bonds, and life insurance policies with cash surrender
value. If yes, please list: |
□ Yes □ No |
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Do you have the
right to sue anyone for any reason? If yes, please explain why: |
□ Yes □ No |
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Do you have any un-filed
tax returns? If yes, for what year(s): |
□ Yes □ No |
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Do you owe any
taxes? If yes, list the amount for each
year owed: |
□ Yes □ No |
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Have you sold,
given away, or transferred any property worth over $500 to anyone in the last
4 years? If yes, please list what you
transferred, to whom, and the value of the property: |
□ Yes □ No |
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Have you been sued
in the last 10 years?
If yes, please list who sued you, the reason they sued you, when you
were sued, and the amount of the claim: |
□ Yes □ No |
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Have you owned a business at any time within the past 6 years? If so, do
you owe any taxes due to that business?
□ Yes □ No |
□ Yes □ No |
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Are you expecting
any tax refunds? If yes, how much: $ Did you get a tax refund? How much? |
□ Yes □ No |
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Have you lived in If not, in
what year did you move to |
□ Yes □ No |
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Are you separated from your spouse or contemplating separation? If yes,
your spouse’s name: |
□ Yes □ No |
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Do you owe any overdue child support? If yes, how much: $ |
□ Yes □ No |
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Are you currently being sued or expect to be sued by anyone? |
□ Yes □ No |
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Do you own any life insurance policies with cash surrender or loan value? |
□ Yes □ No |
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Do you have a retirement account? |
□ Yes □ No |
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Do you receive any money from an
annuity or a trust? |
□ Yes □ No |
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Do you have anything in your
possession that really belongs to someone else? |
□ Yes □ No |
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Does anyone have possession of
anything that really belongs to you? |
□ Yes □ No |
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Do you have any property titled
in your name that really belongs to someone else? |
□ Yes □ No |
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Have you made any purchases over
$500.00 in the last 90 days? |
□ Yes □ No |
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Have you taken out any loans or
cash advances in the last 90 days? |
□ Yes □ No |
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Have you paid back friends or
relatives more than $200.00 in the last 24 months? |
□ Yes □ No |
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Is there anyone threatening to repossess
your vehicles or foreclose on your home? |
□ Yes □ No |
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Are you required to pay any debts
under a Separation Agreement or a Divorce Decree? |
□ Yes □ No |
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Do ex-spouses have any claims
against you? |
□ Yes □ No |
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Did you transfer any of your
property to your ex-spouse? |
□ Yes □ No |
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Have you had any car accidents in
the past 4 years? |
□ Yes □ No |
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Are any of your debts being paid
by payroll deduction? |
□ Yes □ No |
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Are you repaying any 401k loans
or other loans against your retirement? |
□ Yes □ No |
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Have you given any loan company a
list of your household goods? |
□ Yes □ No |
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Has anyone co-signed a loan or
credit card for you? |
□ Yes □ No |
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Has anyone pledged a CD, bank
account, other property so you could get a loan? |
□ Yes □ No |
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Has Anyone served you with court
papers or filed a lawsuit against you in the past 10 years |
□ Yes □ No |
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Have you listed any motor
vehicles as collateral for a personal loan? |