*Name

*Email Address

*Phone Number

Home Number

Work Number

Cell Number

Single  Separated  Married  Divorced 

Employment:

How long at this job?

Occupation

Income paid
weekly  semi-monthly  monthly  other 

Gross

Spouse employment (name and addr.):

Income paid
weekly           

semi-monthly  

monthly          

other            

Gross

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 

Estimated value
$

First Mortgage Loan Balance
$

Loan Current?

Amount Behind
$

2nd Mortgage Loan Balance
$

Loan Current?

Amount Behind
$

Are you facing foreclosure?
Yes  No 

Foreclosure Date

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

Estimate balances owed on all other types of debt listed below

Do you anticipate receiving a tax refund?
Yes  No 

How much?
$

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

Special concerns

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