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Personal Information   First Name Middle Name Last Name E-mail Address: Have you gone by any other name in the last 8 years? if so list full name Social Security Number Street Address City State AL AK AZ AR CA CO CT DC DE FL GA HI ID IL IN IA KS KY LA ME MD MA MI MN MS MO MT NE NV NH NJ NM NY NC ND OH OK OR PA RI SC SD TN TX UT VT VA WA WV WI WY -Terr.- AS FM GU MI PR VI Zip Code County If above address is NOT where you recieve mail please, supply the Street Address where you do If applicable City If applicable State If applicable AL AK AZ AR CA CO CT DC DE FL GA HI ID IL IN IA KS KY LA ME MD MA MI MN MS MO MT NE NV NH NJ NM NY NC ND OH OK OR PA RI SC SD TN TX UT VT VA WA WV WI WY -Terr.- AS FM GU MI PR VI Zip Code If applicable County If applicable Are you married? Yes No Is your spouse filling with you? Yes No Spouse Information If applicable   Spouses First Name Spouses Middle Name Spouses Last Name Has your spouse gone by another name in the last 8 years? if so list full name: Spouse's Social Security Number Spouse's Street Address Spouse's City Spouse's State AL AK AZ AR CA CO CT DC DE FL GA HI ID IL IN IA KS KY LA ME MD MA MI MN MS MO MT NE NV NH NJ NM NY NC ND OH OK OR PA RI SC SD TN TX UT VT VA WA WV WI WY -Terr.- AS FM GU MI PR VI Spouse's Zip Code Spouse's County If above address is NOT where your spouse recieves mail please, supply the Street Address where you do If applicable City If applicable State If applicable AL AK AZ AR CA CO CT DC DE FL GA HI ID IL IN IA KS KY LA ME MD MA MI MN MS MO MT NE NV NH NJ NM NY NC ND OH OK OR PA RI SC SD TN TX UT VT VA WA WV WI WY -Terr.- AS FM GU MI PR VI Zip Code If applicable County If applicable Previous Bankruptcy Information If applicable   Have you filed bankruptcy in the last 8 years? Yes No If yes, what Date did you file? (example 5/30/08) Chapter Filed Case # Property & Mortgage Information If applicable   Do you own property? Yes No If yes, how many properties? 0 1 2 3 Main Property Street Address (If you have more then one property please enter info in space provided at the end of the questionnaire) City State AL AK AZ AR CA CO CT DC DE FL GA HI ID IL IN IA KS KY LA ME MD MA MI MN MS MO MT NE NV NH NJ NM NY NC ND OH OK OR PA RI SC SD TN TX UT VT VA WA WV WI WY -Terr.- AS FM GU MI PR VI Zip Code How much is your house worth? Who is your mortgage with? How much do you owe? If applicable, who is your second mortgage with? How much do you owe? Are you current on the payments? Yes No If not, how many payments have you missed? How much are your monthly mortgage payments? Are taxes & insurance included in your monthly mortgage? Yes No Are there any other names on the mortgage? If Yes, please provide Full Name Checking | Savings | Personal Account Information Checking Account Name Checking Account Balance Checking Account #2 Name Checking Account #2 Balance Savings Account Name Savings Account Balance Savings Account #2 Name Savings Account #2 Balance Do you have any Personal Property worth a substaintial amount of money? If yes please provide item name Personal Property Estimated Value Do you have a Financial Account? (IRA, 401K, Stocks, Bonds, etc.) If yes please provide item name Financial Account Estimated Value Financial Account #2 Financial Account #2 Estimated Value Do you have universal or whole life insurance policy? If yes, provide item Value Do you expect to receive a tax refund this year? Yes No If yes, estimate how much? Automobile & Other Vehicle Information If applicable   Car Year Car Make Car Model Car Mileage Amount Owed Company Car #2 Year Car #2 Make Car #2 Model Car #2 Mileage Car #2 Amount Owed Car #2 Company Do you own a motorcycle, boat, Rv, etc? If yes please provide item name Other Vehicle Model Other Vehicle Mileage Other Vehicle Amount Owed Other Vehicle Company Other Vehicle #2 Make Other Vehicle #2 Model Other Vehicle #2 Mileage Other Vehicle #2 Amount Owed Other Vehicle #2 Company How Much Do You Owe?   Give an estimate of how much you owe in credit cards Give an estimate of how much you owe in medical bills Give an estimate of how much you owe in pay day loans Give an estimate of how much you owe in student loans Give an estimate of how much you owe in governmental debt (fines, taxes, etc.) Do you currently lease an Apartment? If yes, please provide Landlord's name Landlord's Street Address Landlord's City Landlord's State AL AK AZ AR CA CO CT DC DE FL GA HI ID IL IN IA KS KY LA ME MD MA MI MN MS MO MT NE NV NH NJ NM NY NC ND OH OK OR PA RI SC SD TN TX UT VT VA WA WV WI WY -Terr.- AS FM GU MI PR VI Landlord's Zip Code How much was your security deposit? Do you have a co-signer on anything? If yes, Co-Signer Item Co-Signer Name Co-Signer Street Address Co-Signer City Co-Signer State AL AK AZ AR CA CO CT DC DE FL GA HI ID IL IN IA KS KY LA ME MD MA MI MN MS MO MT NE NV NH NJ NM NY NC ND OH OK OR PA RI SC SD TN TX UT VT VA WA WV WI WY -Terr.- AS FM GU MI PR VI Co-Signer Zip Code Employment & Income Information   Name of your employer Employer Street Address Employer City Employer State AL AK AZ AR CA CO CT DC DE FL GA HI ID IL IN IA KS KY LA ME MD MA MI MN MS MO MT NE NV NH NJ NM NY NC ND OH OK OR PA RI SC SD TN TX UT VT VA WA WV WI WY -Terr.- AS FM GU MI PR VI Employer Zip Code What is your occupation? How many years have you worked at your current job? What is your monthly gross income? (before taxes) What is the name of your spouses employer? Spouse Employer Street Address Spouse Employer City Spouse Employer State AL AK AZ AR CA CO CT DC DE FL GA HI ID IL IN IA KS KY LA ME MD MA MI MN MS MO MT NE NV NH NJ NM NY NC ND OH OK OR PA RI SC SD TN TX UT VT VA WA WV WI WY -Terr.- AS FM GU MI PR VI Spouse Employer Zip Code What is your spouses occupation? How many years has your spouse worked at there current job? What is your spouses monthly gross income? (before taxes) Other Monthly income Source (if applicable) Other Monthly Income Amount (if applicable) Other Monthly income Source #2 (if applicable) Other Monthly income Amount #2 (if applicable) Dependents If applicable   How many dependents do you have? 0 1 2 3 4 5 If applicable: #1 Dependents Sex Male Female If applicable: #1 Dependents Age If applicable: #2 Dependents Sex Male Female If applicable: #2 Dependents Age If applicable: #3 Dependents Sex Male Female If applicable: #3 Dependents Age If applicable: #4 Dependents Sex Male Female If applicable: #4 Dependents Age If applicable: #5 Dependents Sex Male Female If applicable: #5 Dependents Age Monthly Spending & Bills   How much is your electric & gas monthly? How much is your water & sewer monthly? How much is your house phone monthly? How much is your cell phone monthly? How much is your cable monthly? How much is your internet service monthly? How much is your food monthly? How much do you spend on clothing monthly? (average) How much do you spend on Dry Cleaning monthly? How much do you spend on medical/prescriptions monthly? (out of pocket) How much do you spend on gas/public transportation monthly? How much do you spend on recreation/entertainment monthly? How much do you make in charitable contributions monthly (Must have proof) How much do you pay for homeowners insurance? (if not included in mortgage payment) or renters insurance monthly? How much do you pay in automobile insurance monthly? How much do you pay in health insurance monthly? (Out of pocket) How much do you pay in life insurance monthly? (Out of pocket) If property taxes are not included in your mortgage, how much on average would you pay monthly? How much are your car payments? How much do you pay for child support, or alimony monthly? Do you have any other necessary monthly expenses not included? Please Explain How much do your last years taxes say you made? How much do your 2008 taxes say you made? Have you paid a creditor over $600 in the last 90 days? If yes, Who How much? Are you currently or have you been sued by anyone? If yes, Who For how much? Are you currently being garnished or have a wage assignment? If yes, please provide info Foreclosures & Repossessions   Have you had any foreclosures or repossessions in the last year? Yes No If yes, Creditor Name If yes, Item If yes, date taken (example 5/30/08) If yes, value Loss or Transfers of Money   Have you had any loss from fire. theft, or any other casualty in the last year? If yes please explain Have you transferred any money, goods, or any other valuable into someone elses name within last 3 years? If yes, please explain Account Closings   Have you closed any financial accounts with the last year? If yes, please provide the type If yes, please provide the value If yes, please provide the date when closed (example 5/30/08) #2 Account Type #2 Account Value #2 Date of Closing (example 5/30/08) #3 Account Type #3 Account Value when closed #3 Date of closing (example 5/30/08) Safe Deposit Box   Do you have a safe deposit box? If yes, please provide description and value Previous #1 Street Address Previous #1 City Previous #1 Address State AL AK AZ AR CA CO CT DC DE FL GA HI ID IL IN IA KS KY LA ME MD MA MI MN MS MO MT NE NV NH NJ NM NY NC ND OH OK OR PA RI SC SD TN TX UT VT VA WA WV WI WY -Terr.- AS FM GU MI PR VI Previous #1 Zip Code Previous #2 Street Address Previous #2 City Previous #2 State AL AK AZ AR CA CO CT DC DE FL GA HI ID IL IN IA KS KY LA ME MD MA MI MN MS MO MT NE NV NH NJ NM NY NC ND OH OK OR PA RI SC SD TN TX UT VT VA WA WV WI WY -Terr.- AS FM GU MI PR VI Previous #2 Zip Code Previous #3 Street Address Previous #3 City Previous #3 State AL AK AZ AR CA CO CT DC DE FL GA HI ID IL IN IA KS KY LA ME MD MA MI MN MS MO MT NE NV NH NJ NM NY NC ND OH OK OR PA RI SC SD TN TX UT VT VA WA WV WI WY -Terr.- AS FM GU MI PR VI Previous #3 Zip Code Please use this space to provide any other information you could not fit into space provided above, or use the space to explain anything else you may feel is important to your case: If you have some files you would like to supply you can upload them now: (File size limit is 2MB COMBINED) We accept: Word files, PDFs, Jpegs, and Txt files Please note: If you are sending files please allow adequate time for uploading! 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