Date:



Date: ______________________________

How did you hear about us? ______________________________

General Information

Name: _______________________________________ Birth date: ____/____/______ SSN: ___________________

First Middle Last

Spouse: ______________________________________ Birth date: ____/____/______ SSN: ___________________

First Middle Last

Address: ____________________________________________ City, St, ZIP: __________________________

Home phone: (____) ____-______ Work: (____) ____-________ County: ______________________________

Do you have any children living at home? (name, age): _____________________________________________

Marital Status: _________________________________

Have you ever filed bankruptcy before? _______ When / Where? ____________________________________

Email address___________________________________________________________

Employment Information

Your employer: ____________________________________ Occupation: ______________________________

How long employed? __________ Paid: Wkly ____ Bi-wkly ____ Monthly ____ Bi-monthly ____ Other ____

If less than 6 months:

Previous employer: _________________________________ Occupation: ______________________________

How long employed? __________ Paid: Wkly ____ Bi-wkly ____ Monthly ____ Bi-monthly ____ Other ____

Spouse’s employer: ________________________________ Occupation: ______________________________

How long employed? __________ Paid: Wkly ____ Bi-wkly ____ Monthly ____ Bi-monthly ____ Other ____

If less than 6 months:

Previous employer: _________________________________ Occupation: ______________________________

How long employed? __________ Paid: Wkly ____ Bi-wkly ____ Monthly ____ Bi-monthly ____ Other ____

Please bring a recent pay stub from every current employer to your appointment.

Debt Information

Do you: Own your home? ______ Rent? ______ Other? ______

Are you behind in mortgage or rent payments? YES NO amount $___________________

Do you owe the IRS? YES NO amount $___________________

Do you have any outstanding Insufficient Funds checks? YES NO amount $___________________

Were any of these covered with bank Overdraft Protection? YES NO amount $___________________

Do you owe state taxes? YES NO amount $___________________

Do you owe student loans? YES NO amount $___________________

Are you behind in child or spousal support? YES NO amount $___________________

Do you have any co-signers on any of your debts? YES NO amount $___________________

Are you named as a co-signer / co-debtor on any loans? YES NO amount $___________________

For office use only:

Secured Debt Information

(Debt with collateral attached to it.)

Home / Real Estate: (List your home even if there is no debt against it.)

Monthly payment $_________ Balance due $_____________ Behind? YES / NO Amount $_____________

Home / Land Value on Property Tax statement $_____________

Monthly payment $_________ Balance due $_____________ Behind? YES / NO Amount $_____________

Home / Land Value on Property Tax statement $_____________

Monthly payment $_________ Balance due $_____________ Behind? YES / NO Amount $_____________

Home / Land Value on Property Tax statement $_____________

Vehicles: (List all vehicles in your name even if there is no debt against it.)

Yr./Make: _____________________________________ Payment $__________ Balance due $______________

Purchase date: _______________ Retail Value $____________ Miles _______________

Yr./Make: _____________________________________ Payment $__________ Balance due $______________

Purchase date: _______________ Retail Value $____________ Miles _______________

Yr./Make: _____________________________________ Payment $____________ Balance due $______________

Purchase date: _______________ Retail Value $_____________ Miles ______________

Recreational vehicles, motorcycles, boats, trailers, etc.: (List all in your name even if there is no debt against it.)

Description: ___________________________________ Payment $___________ Balance due $______________

Purchase date: _______________ Retail Value $______________

Description: ___________________________________ Payment $____________ Balance due $______________

Purchase date: _______________ Retail Value $______________

Other Secured loans: (For furniture, appliances, electronics, and other purchases that have collateral as security.)

Description: ___________________________________ Payment $____________ Balance due $______________

Purchase date: _______________ Retail Value $______________

Description: ___________________________________ Payment $____________ Balance due $______________

Purchase date: _______________ Retail Value $______________

Description: ___________________________________ Payment $____________ Balance due $______________

Purchase date: _______________ Retail Value $______________

Do you have any debt(s) that have been charged off? Circle one: YES OR NO

Have you received a 1099 for this charge off? Circle one: YES OR NO If yes, did you include this in your tax return? Circle one: YES OR NO

Unsecured Debt Information

(Debt without collateral attached to it.)

List all debts even if you dispute them or if they have been “written off” by a creditor, including credit cards, medical debts, personal loans, “pay day” loans, old utility or cell phone bills, bad checks, etc.

|Name of Creditor |Creditor Type |Monthly payment |Balance Owed |Payments behind? |

| |(Credit Card, Medical, | | | |

| |Loan, Utility) | | | |

|1 | | | |Yes No |

|2 | | | |Yes No |

|3 | | | |Yes No |

|4 | | | |Yes No |

|5 | | | |Yes No |

|6 | | | |Yes No |

|7 | | | |Yes No |

|8 | | | |Yes No |

|9 | | | |Yes No |

|10 | | | |Yes No |

|11 | | | |Yes No |

|12 | | | |Yes No |

|13 | | | |Yes No |

|14 | | | |Yes No |

|15 | | | |Yes No |

|16 | | | |Yes No |

|17 | | | |Yes No |

|18 | | | |Yes No |

|19 | | | |Yes No |

|20 | | | |Yes No |

Are your wages now being garnished, or are they about to be garnished? YES NO

Details: ______________________________________________________________________________________________

Do you have any judgments or lawsuits against you? YES NO

Details: ______________________________________________________________________________________________

Do you have any loans against your retirement fund or 401K? YES NO

Details: ______________________________________________________________________________________________

Have you borrowed money, taken out new loans or extensions of existing loans, opened new credit card accounts, or otherwise incurred any new debt in the last 60 days? YES NO

Details: ______________________________________________________________________________________________

Have you purchased “luxury items,” such as jewelry, expensive electronics, etc. on credit, or made any large cash advances on your credit cards in the last 60 days? YES NO

Details: ______________________________________________________________________________________________

Do you owe money to friends or family members? YES NO

Who? ______________________________________________ Amount $____________

Monthly Expenses

Give your estimated current average monthly household expenses.

Your total monthly take-home (net) pay $___________

Spouse’s total monthly take home pay $___________

Other monthly income (Social Security, disability, child support, etc) $___________

Other _______________________________________________ $___________

Total monthly income $___________

Home expenses:

Rent / Mortgage payment (including any assessment or maintenance fee) $___________

Real Estate taxes not included in your mortgage payment $___________

Utilities:

Electric: $_________

Gas $_________

Water $_________

Telephone $_________

Cell Phone $_________

Garbage $_________

Cable / Satellite $_________

Internet $_________

Other $_________

Total Utilities: $____________

Home Maintenance (What is normally spent for light bulbs, the lawn, and care for the home?) $___________

Other expenses:

Taxes not deducted from wages or for land $___________

Alimony or child support (not already deducted from paycheck) $___________

Insurance:

Life $___________

Health $___________

Auto $___________

Home / Renters $___________

Other $___________

Total Insurance: $____________

Installment Payments:

Vehicle(s) $___________

Other $___________

Other $___________

Total Installments: $____________

Transportation (gasoline and car maintenance – not repairs) $___________

Education (school lunches, after school activities for children) $___________

Food / household supplies $___________

Clothing $___________

Medical, dental, and regular medicines $___________

Laundry and dry cleaning $___________

Newspapers, periodicals, and books $___________

Recreation, clubs, and entertainment $___________

Charitable contributions $___________

Child care $___________

Other expenses (specify) ___________________________________________________ $___________

TOTAL ESTIMATED CURRENT MONTHLY EXPENSE: $___________

ATTORNEY NOTES

-----------------------

Law Office of Phil Black

136 W. Twohig, Suite B

San Angelo, TX 76903

Office: 325-659-5011

Fax: 325-482-0156

YES NO

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