Section 1  Basic Information

 Name and Address

Name:    ________________________________________________________________________________

  Last First  Middle

Telephone Number   Home:___________ Work: Cell_____________Email__________________

Have you used any other names in the past eight years?     No      Yes    If yes, list other names:

___________________________________________________________________________________

Social Security Number:   ___  ___  ___  -  ___  ___  -  ___  ___  ___  ___

Marital Status (circle one):   Single          Married          Separated            Divorced         Widowed

Address: _____________________________________________________________________________

City: _________________________  State:____________Zip:  _________________________________

County: _________________________

Have you lived at this address for at least 180 days?   No     Yes 

Have you lived at this address for at least 3 years?   No     Yes

If you answered no to either of the questions above, please list your previous address:

 Address:__________________________________________________________________________

 City:______________________  State:______________ Zip:  ________________

 County:____________________

If you have a different mailing address, please list:

Mailing Address:_________________________________________________________________________

City: _________________________  State:____________Zip:  _________________________________

Name and Address of Spouse

This is required regardless of whether your spouse will file with you:

Name:   

  Last First  Middle

PHONE HOME_________________ WORK______________CELL_______________ EMAIL_______________________

Has your spouse used any other names in the past eight years?     No      Yes  If yes, list other names:

Social Security Number:   ___  ___  ___  -  ___  ___  -  ___  ___  ___  ___

Marital Status (circle one):      Single           Married           Separated         Divorced        Widowed

Address: (if different from your address): ___________________________________________________

City: _________________________  State:________  Zip:________________  County: 

If your spouse has a different mailing address, please list:

Mailing Address:_________________________________________________________________________

City: _________________________  State:____________Zip:  _________________________________

Prior/Pending Bankruptcy Cases

Has a bankruptcy case been filed by you or against you in the last 8 years?    No      Yes

If yes, provide inormation on case filed?  _________________________________________

Case Number: _______________________Date filed:  __________________________________________

Are there currently any bankruptcy cases pending against you, your business,corpotation,, parnership, your spouse, or your spouse’s business?     No      Yes

If yes, name of debtor: _______________________________ Relationship to you: ____________________

Case Number: __________________Date filed: ______________

In which district of which state was the case filed?  

If you rely on income from a person who is not your spouse please provide information

Domestic Relations Order of Support Verification 

         (Please fill out a form for each divorce decree orJuvenile court order or order of support.)

 Case No.____________________

Type of Court Ordered Support:    Child       Spousal        Debts pursuant to a divorce decree

Name of Ex-spouse or other person___________________________ Phone__________________

Address___________________________ ___________________________

Email_________________________________________

Name of Support Enforcement Agency (SEA)________________________________

Address of SEA________________________________________________________

                           ________________________________________________________

Monthly Payment____________________________

Amount of Past Due Payment___________________

Copy of Divorce Decree or Support Order Attached:    Yes    No

Number of Children___________

(The following information regarding your children is CONFIDENTIAL and is for the use of this LAW OFFICE ONLY.)

Name    Date of Birth    Age   Disabled?

 Address  ___________________________________________________________________________________________

 Are You behind?                           

 If so how much do yo owe on an arrearage? __________________________________

 What is the balance owe on this mortgage? ___________________________________

Do you have a Second Mortgage or lien? _____

If so, who is this debt owed to? ________________________________________________________                                            

Address?

 Monthly Payment

 If so, how much do you owe on an arrearage ________________________________________

How much do you owe on this debt? ____________________________________________________________________                   

 Name & address of Second Mortgage of Lien Holder ________________________________________ Addreess _________________________________________________________________________

When did you acquire this debt?__________________                                     

 Monthly  Payment _________________________

:Are You Current on this Obligation: Yes___ No_____         

 OTHER REAL PROPERTY

address?__________________________________________________________

 Is tis Rental Property?

  If So, how much do yeu receive in rent?

   First Mortgage:

Does the second mortgage have any additional security such as vehicles listed as collateral? ___________

If so, please list:_________________________________________________

_________________________________________________________________________________

*If you have additional mortgages on your real estate or own any other pieces of  real estate, empty lots, or timeshares please ask the secretary for more paperwork.                                                                       

Motor Vehicles/Mobile Homes

Please list all vehicles titled in your name even if you do not owe money on the car, or even if someone else regularly drives the vehicle, or even if the vehicle does not run.

If you do not have a vehicle titled in your name, please indicate your method of transportation.                                   

VEHICLE #1

Description (Yr. & Make):________________________________________________________

Titled in the name:______________________________________________________________

Amount owed:__________________________   Monthly payment:_____________________

Current Value:_______________________ Mileage:_____________________________

Equity:                               (For Attorney Only)  Vehicle ID No._______________________________________________  

Is there any damage?________________________________________________________

Name & Address of Creditor:________________________________________________________________________________

Date of Purchase:___________________ Original Length of Loan:__________________       Interest Rate:______________

Is anyone else responsible for this debt? Please note their name, address and relationship to you:

________________________________________________________________________________________________________

Is this a leased vehicle?____________ When was the vehicle leased?____________________   Term of the lease_____________

Has this vehicle been repossessed or is it close to being repossessed?    ________________________________      

ADDITIONAL MOTOR VEHICLES  

Description (Yr. & Make):________________________________________________________

Titled in the name:______________________________________________________________

Amount owed:__________________________   Monthly payment:_____________________

Current Value:_______________________ Mileage:_____________________________

Is there any damage to this car? ________________________________________________________

Name & Address of Creditor:____________________________________________________________________________________

Date of Purchase:___________________ Original Length of Loan:__________________       Interest Rate:______________

Is anyone else responsible for this debt? Please note their name, address and relationship to you:

___________________________________________________________________________________________________________

Is this a leased vehicle?_______________ When was the vehicle leased?____________________   Term of the lease_____________

Has this vehicle been repossessed or is it close to being repossessed?   _____________________________       

Do you have any other vehicles even if driven by a relative?  If so, please see the secretary for an additional form.

Household Goods and Furnishings

For personal, family and household purposes the replacement value is the value a retail merchant selling the item would charge considering the age and condition of the item.  Example: Assume that you have a television that is 5 years old.  You have been using it regularly and it works.  The replacement value for this item would be what a used item like this would sell for in a yard sale or auction.

Kitchen:

            Stove/Range

            Refrigerator

            Freezer

            Small Appliances

            Table/Chairs

            Hutch

Dining Room, Living Room Family Room

            Table/Chairs

            Couch/recliner

            Hutch

            Server

            China/Dishes __________

            Antiques    ____________

Electronic Equipment

            Televisions/entertainment Center ___________

            Stereo/cd or video players.        ___________

            Video Games

Memorabilia

            Sports Memorabilia  ___________

Garage

            Tools

            Power Equipment

            Riding Mowers            ____________

 Other

            Firemarms                     ____________

            Golf Clubs/Sports Equipment ________

            Livestock or Horses       ____________

            ATV, Jet Skis orother    ____________

Are you paid weekly?, every other week, 2x/month, monthly, other?

Average Gross Wage Pay               $____________

Social Security/Pension/Retirement

$_____________

Net Rental Income (direct expenses deducted)

$_______________

 Net Business Income

$______________

Spouses Gross Wage Pay

$______________

 how often paid?_________________

 Income from other Sources

$_______________

 TAXES DEDUCTED FROM GROSS WAGES

You ___________

Spouse ________

 OTHER DEDUCTIONS FROM WAGES

(such as insurance, union dues, 401K, pension, stocks, tools, etc.)

____________________________________

____________________________________

____________________________________

____________________________________

TOTAL MONTHLY INCOME

(Add Total Income and Subtract taxes and other deductions

$___________________________________

MONTHLY EXPENSES

Rent/Mortgage $_______________

Gas/Electric $_____________________

Telephone/cellphone________________

Cable/Internet/bundling $_____________

Trash/Water/Water Softener$_________

 Security System $__________________

Newspaper/Magazines $_____________

 Home Repairs $___________________

Food/School Lunches/Cigarettes/Alcohol

Eating Out         $___________________

Clothing             $___________________

Medical             $___________________

Auto Ins             $___________________

Health Ins          $___________________

Life Ins               $___________________

Gasoline/Car Repairs/Registration/Licensing

& other transportaiton $______________

Child Care        $___________________

Car Payments   $___________________

                            $___________________

                            $___________________

Other Monthly Payments $____________

                            $___________________

                            $___________________

 TOTAL MONTHLY EXPENSES

                           $___________________

EMERGENCY CIRCUMSTANCES

Have any creditors sued you?

Have any vehicles been repossessed or about to be repossessed?

 Has a forclosure been filed against you or is one about to be filed? ______ If the answer is yet when was the filing?