Interview

Marital Status:  Married     Single

Have you ever filed for bankruptcy before?:   no     yes

Your full name: 

Your Social Security number: 

Spouse's full name: 

Spouse's Social Security number:  

Home address: 

City:       State:       Zip Code:  

Telephone:      Email 

HUSBAND (if applicable)

Are you employed?    Yes     No     Self Employed

What is your occupation?: 

Your employer's name:  

Your work telephone number:  

How long have you been employed?: 

How often are you paid?:    Weekly     Bi-weekly     Twice monthly

What are your gross wages per pay period?: 

What is your take home (net) per pay period?: 

Do you have any other source of income?:    Yes     No

(unemployment, AFDC, spousal or child support, trust income, etc.)  

Please identify other income source: 

Other income source amount:  

WIFE (if applicable)

Are you employed?    Yes     No     Self Employed

What is your occupation?: 

Your employer's name:  

Your work telephone number:  

How long have you been employed?: 

How often are you paid?:    Weekly     Bi-weekly     Twice monthly

What are your gross wages per pay period?: 

What is your take home (net) per pay period?: 

Do you have any other source of income?:    Yes     No

(unemployment, AFDC, spousal or child support, trust income, etc.)  

Please identify other income source: 

Other income source amount:  

Residence (and other real estate)

Do you own or rent?:    Own     Rent

If renting, how much monthly?: 

If you own, what is the value of your residence?: 

How much do you owe on the property (total)?: 

1st Mortgage (if applicable)

Name: 

Amount:      Monthly Payment:  

Are you current?:    Yes     No     If behind, how far?: 

2nd Mortgage (if applicable)

Name: 

Amount:      Monthly Payment:  

Are you current?:    Yes     No     If behind, how far?: 

Do you intend to stay?:    Yes     No

Do you own any other real estate?:    Yes     No

Describe other real estate: 

Value of other real estate:  

Vehicles

1st Vehicle (if applicable)

Year and make of car:  

Value of car (low blue book)?: 

Do you own money on this car?:    Yes     No

If yes, to who?: 

Total amount owed:      Monthly payment: 

Number of payments left: 

2nd Vehicle (if applicable)

Year and make of car:  

Value of car (low blue book)?: 

Do you own money on this car?:    Yes     No

If yes, to who?: 

Total amount owed:      Monthly payment: 

Number of payments left: 

Do you own or lease any other vehicles? (describe):

Bank Accounts and Other Assets

Do you have a checking or savings account?:    Yes     No

Name of bank or institution: 

Approximate balance: 

Other deposit accounts:  

Any other assets (not including ordinary household goods)?:  

Liabilities

Other than mortgages and lienholders on vehicles, do you have any other secured debt? (in other words, are you financing any other merchandise, such as furniture, jewelry, boats, electronic equipment, etc.):    Yes     No

If so, describe collateral:      Value: 

Name of creditor: 

Total amount owed:       Monthly payment:  

Number of payments remaining:  

Other merch. financed:      Value: 

Name of creditor: 

Total amount owed:       Monthly payment:  

Number of payments remaining:  

Do you owe any taxes?:     Yes     No     Total amount owed: 

Do you owe any court fines (such as DUI's), back spousal support, student loans, welfare, or social security overpayment?    Yes     No

List All Remaining Creditors

Name:       Amount:  

Describe:  

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Submit Interview For Review

Carefully review the contents of the interview form and when you are finished select the "Submit Interview" button below to send it for review.