Can I file? Name * Phone Number (Put if you want me to contact you by phone) E-mail (Put if you want me to contact you by e-mail) City where you live * Ever filed bankruptcy before? * Yes No If so, what year? How many automobiles do you have with your name on the title? * Of those automobiles, how many do you still owe money on? How much are your total monthly automobile payments, if any? Do you own a boat, motorcycle, or travel trailer? * Yes No How much do you pay each month, if anything, for the above? Do you own any time-share condos? * Yes No Do you own any stocks, bonds or other investments outside of a retirement account? * Yes No Do you own the home you live in? * Yes No How much is your monthly mortgage/rent payment? Do you own land other than the land you live on? Yes No Have you been employed within the last 2 months? * Yes No Have you been self-employed or owned a business within the last 5 years? Yes No What is your current gross income from work (how many $ per wk/mo/yr) How much did you report as your gross income on last year's taxes (if you are/were married, combined with spouse's income)? How much do you pay, if anything, each month toward student loans? Are you currently married and living with a spouse? * Yes No If married, what is your spouse's current gross income (how many $ per wk/mo/yr)? How many children under 18 reside in your home with you? How much do you pay each month, if anything, for child care expenses for children in or outside your home? How much do you pay each month, if anything, for alimony and/or child support for children living outside your home? How much do you and/or a spouse residing with you receive, if anything, for child support? Do you plan to file bankruptcy within the next month? * Yes No If you retain me, do you wish to meet me in my office or retain me by mail?

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