The Fleck Law Group  

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Fill out as much INFO ON EACH TAB as possible!
   
  • Debt
  • Assets
  • Employment
  • Info & Schedule
1 Check all
that apply
Credit Cards
Judgements
Tax Debts
Personal Loans
Medical Bills
Student Loans
Government Fines
2 Total Amount of
unsecured debt
Under $5,000
$5,000 - $10,000
$10,000 - $15,000
$15,000 - $20,000
$20,000 - $30,000
$30,000 - $40,000
$40,000 -$50,000
Over $50,000
3 Do you own Real Estate?
Yes No
4 Are you current on your payments?
Yes No
5 How much Equity do you think is in your home?
6 Do you own a car?
Yes No
7 Are you current on your payments?
Yes No
8 How much equity do you think is in your car?
9 Are you employed?
Yes No
10 How often do you get paid?
Every Week
Twice a Month

Every 2 Weeks
Monthly
11 Gross pay
(after taxes, medical, and other deductions)
12 Optional How often does your spouse get paid?
Every Week
Twice a Month
Every 2 Weeks
Monthly
13 Optional Spouse's gross pay
(after taxes, medical, and other deductions)
14 Name*
15 Address
16 City*
17 State
18 Zip code
19 E-mail Address*
21 Best date/time to reach you*
Morning Afternoon Night
23 Best Phone number to reach you*

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