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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