Chapter 13 Contact Form

*First Name

*Last Name

*Email Address

*Phone Number

*Zip

Street Address

Apt/Ste

Incident Street Address

Incident Apt/Ste

*Incident Zip

Do you intend to file a joint bankruptcy petition?
Yes  No 

If yes, include information for both yourself and your spouse below.

Name(s), including middle initial.

Residence address, including county.

How long have you been at this address?

Other telephone number(s)

Work

Cell

Other

Have you used any other name(s) in the last six years?
Yes  No 

If yes, please list here

Single  Separated  Married  Divorced 

If married, how long?

If divorced, how long?

Ages of minor children living with you

Ages, and amount of child support paid:

Is any child support past due?
Yes  No 

Amount
$

Husband's employment:

How long at this job?

Occupation

Income paid
weekly  semi-monthly  monthly  other 

Gross

Net

Wife's employment (name and addr.):

How long at this job?

Occupation

Income paid
weekly  semi-monthly  monthly  other 

Gross

Net

Income from other sources (second job, investments, social security, child support, worker's compensation, etc. (state source and amount):

Do you owe any money to the Internal Revenue Service?
Yes  No 

If yes, for what year(s)?

How much?
$

Do you have any unpaid student loans?
Yes  No 

Amount
$

Monthly Expenses

Do you pay anyone spousal support (alimony)
Yes  No 

If yes, to whom and how much?

Do you own or are you purchasing a home or other real property?
Yes  No 

Tax assessed value
$

First Mortgage Loan Balance
$

Loan Current?

Amount Behind
$

2nd Mortgage Loan Balance
$

Loan Current?

Amount Behind
$

3rd Mortgage Loan Balance
$

Loan Current?

Amount Behind
$

Are you facing foreclosure?
Yes  No 

Foreclosure Date

List any liens against your property

List all vehicle loans (car, truck, motorcycles; identify vehicle type)

List all vehicles you own outright (no loan balance)

Have you purchased any secured items (electronics, boats, jet ski, appliances, etc.) in the last two years on which you still owe money?
Yes  No 

Have you taken out a loan from a finance company, credit union, bank, or any other place and secured the loan by household items or other type of secured collateral?
Yes  No 

Creditors' Names

Estimate balances owed on all other types of debt listed below

When was the last time you used any of your credit cards? (approx. date)

How much has total owed on cards gone up in the last 12 months?

Have you had any new cards issued in the last 12 months?

Do you anticipate receiving a tax refund?
Yes  No 

How much?
$

Are you eligible for the Earned Income Credit?
Yes  No 

How much?
$

List all judgments, lawsuits, liens, and garnishments against you.

List all other assets not disclosed above, including bank accounts, stocks, bonds, trust funds, real property, home furnishings, etc.

Special concerns

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