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  ONLINE BANKRUPTCY EVALUATION  
     
  Please answer the following questions to the best of your knowledge  
     
 
GENERAL INFORMATION  
First name: Last Name:
Address:
Phone Number: Email Address:
UNSECURED DEBT
Types of Debt:
 
Medical Bills
 
Amount Owed:
 
YOUR HOME / MORTGAGE
Value of Home (estimate) Mortgage Balance (estimate)
  $  $
Monthly Mortgage Payment  
  $  
Is your Mortgage Current?
 
VEHICLE INFORMATION
Vehicle 1 (Year, Make, Model)
Market Value (estimate) Balance Owed (estimate)
 $  $
Monthly Payment  
 $  
Are your payments current?  
Yes No
   
Vehicle 2 (Year, Make, Model)
Market Value (estimate) Balance Owed (estimate)
 $  $
Monthly Payment  
$  
Are your payments current?
Yes No
List any other Assets or Debt of Significant Value here
 
YOUR EMPLOYMENT / INCOME
Are you employed?
No
Net Pay from Employment (after taxes, medical and deductions)
 $
 
Other Income (do not include Spouse’s income)
 $
 
SPOUSE’S INCOME
Net Pay (after taxes, medical and deductions)
 
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