Financial form: Tax, Bankruptcy, Debt Law, Tax Attorney, Bankruptcy Lawyer, Debt relief agencies

* First, Middle, Last Name

Other names used by you

* Social Security Number

* Date of Birth (MM/DD/YY)

* Home Address (Street, City, State, Zip)

Mailing Address (Street, City, State, Zip)

* Telephone Number (area code) + (number)

Email address

Please list addresses in which you have resided in the past five (5) years

	Address	Dates of Occupation (MM/YY) - (MM/YY)
Location # 1
Location # 2
Location # 3

* Marital Status

Single

Married

Divorced

Seperated

If married or separated, does your spouse maintain a separate household from you?

Yes

If divorced date of marrigage and divorce?

	Dates of Marriage (MM/YY)	Date of Divorce (MM/YY)
Location # 1

Address of former spouse?

	Address	City / Zip

Does your spouse plan to file bankruptcy with you?

Yes

SECTION II: INFORMATION ABOUT YOUR CURRENT SPOUSE

First, Middle, Last Name

Social Security Number

Date of Birth (MMDDYY)

Other names used by your spouse

Spouse's address (only if different from yours)

If either you or your spouse have ever filed for bankruptcy please list that information here

	Name filed under (first,middle,last)	City, State filed in	Date	Type of Bankruptcy (Chapter 7 or Chapter 13)
You
Spouse

Please list information on your Dependents (persons who rely on you or your spouse for support)

	FIRST, MIDDLE, LAST NAME	RELATIONSHIP	AGE
Dependent #1
Dependent #2
Dependent #3

SECTION III: Employer Information / Income

Employer Information

	Debtor	Spouse
Employer Name
Length of Employment
Position title

Source of Income (List Gross Monthly Amount $)
For example Wages -- For $3,000.00 Enter 3000 (no commas or dollar signs)
Note you can divide annual Salary by 12 to get Monthly Gross

	Wages	Unemployment Benefits	Public Assistance (including food stamps)	Alimony (received by you as the payee)	Child Support (received by you as the payee)	Investments	Retirement (Social Security)	Pension	Other
You
Spouse

SECTION IV: PROPERTY / ASSETS

If you do not own your home, please list the person you rent from or live with

	Name	Address
Landlord
Person you reside with

Please list all real property (real estate) you own

	Address (street, city, state)	Jointly owed with spouse (Yes or No)
Property # 1
Property # 2
Property # 3

Please list the information on your home or homes (real property, mobile homes, parcels of land

	Fair Market or Tax Value of Home $	Mortgage Lender's Name	Loan Number (account #)	Amount of Loan	2nd Mortgage Lender's Name (if applicable)	Loan Number (account #)	Amount of Loan
Property #1
Property #2
Property #3

What do you plan to do with these properties?

Primary Residence
Rental Property
Other Property

Information on 1st Vehicle

	Yes	No
Do you own this vehicle?
Do you own this vehicle?
Are you financing this vehicle?
Are you leasing this vehicle?
Do you wish to keep this vehicle?

Information on 2nd Vehicle

List information about your vehicle or vehicles

	Make/Model	Mileage	Year	Vin#	Fair Market Value (what is the car worth	Balance on Loan	Monthly Payment	Lender/Leasing Company's Name	Loan or Lease Account #
Car # 1
Car # 2

Please list personal property
Indicate whether this is your property or your spouse

	Description, Location of property, Value $ of property
Cash
Bank Accounts (List bank Name)
House furnishings
Furs, Jewelry
Clothing, Medical Aids
Books, art, collectibles
Stocks/Bonds
Retirement Accounts: List type (401k, pension, ira)
Life Insurance Policy: List Company: Policy #: Term/Life: Face Value: Cash Surrender: (attach declarations)
Office Equipment
Estimated tax refund
Motorized vehicle (boat, motorcycle, ect)
Recent or vested Inheritance
Worker's compensation / personal injury claims: Amount you seek gain or have received within last year
Other

SECTION V: DEBTS / LIABILITIES

Do you owe any taxes to Federal (IRS), State, or Local Governmental Entity?

	Agency Name	Amount	Tax Year or Years
Debt # 1
Debt # 2
Debt # 3

Domestic Support Obligations (that you must pay)

	Amount paid monthly	Payee's (First, Middle, Last Name)	Payee's address
Child Support
Alimony
Other

Loans (installments, student, personal)

---NOTE DO NOT INCLUDE MORTGAGE OR CAR PAYMENTS PREVIOUSLY LISTED ABOVE----

	Other Debt type (unpaid medical bills, contractual obligations)	Amount owed $ (whole dollar amount no comma, decimals)	Creditor Name	Account Number
# 1
# 2
# 3

MONTHLY EXPENSES

	LIST MONTHLY AMOUNT
RENT/MORTGAGE
Real estate taxes (if not included in mortgage)
ELECTRICITY
WATER/SEWER/TRASH
GAS/HEATING
TELEPHONE
FOOD
CLOTHING
LAUNDRY/DRY CLEANING
HOME INSURANCE (if not included in mortgage payment)
LIFE INSURANCE
HEALTH INSURANCE
OTHER MEDICAL EXPENSES NOT COVERED BY INSURANCE
AUTOMOBILE INSURANCE
CHILD CARE
RECREATIONAL EXPENSES
EXPENSE FROM OPERATION OF BUSINESS
ALIMONY/ CHILD SUPPORT
CHARITABLE CONTRIBUTIONS
OTHER

If you had any accounts closed by a creditor in the last 12 months

	Creditor's Name	Account number	Final Balance of Debt
Account#1
Account#2

If you have had assets/property seized, garnished, foreclosed upon by a creditor in the last 24 months, Please list property description, creditor's name, date of seizure (attach any paperwork)

If you have been sued in the last two years, please provide 1. the name of the party who sued you, 2. Case #, and 3. County in which the lawsuit was filed

Co-debtors (Not current spouse) which you have joint debts with, Please list their full name, address, amount of debt, description, and account number.

Other information you would like to share, regarding your finances, reason for filing, ect.

* Indicates Response Required

FINANCIAL FORM