Bankruptcy Client Questionnaire
Today’s date:__________
P. O. Box 3624 Huntington Beach, CA 92605 800-620-9204 [email protected]
Your Name :______________________________ Date of Birth:___________________ Your address:___________________________________________ Apt. #:_____ City:
State:
Hm phone:
Zip:
Rent Own
County:___________________________________
_____ Wk phone:
___ Mobile: _________________ ______
E-Mail address:____________________________________________________________________________ Spouses Name :_____________________________ Date of Birth:_________________ Spouses address (if different from your own:_____________________________________________________ City:_________________ State:_____ Zip:____________ County:___________________________________ Home phone:____________ Work phone:________________ Mobile:_______________________________ E-Mail address:____________________________________________________________________________ If you have lived in your home for less than 1 year, please list your previous address: Address:_________________________________________ City:___________________________________ State:___________ Zip:________________ County:_____________________________________________ “NOTE YOUR IMMEDIATE GOALS” __________________________________________________________________________________________ __________________________________________________________________________________________ __________________________________________________________________________________________ __________________________________________________________________________________________ ____________________________________________________________________________________
Please fax the below listed information: Mortgage Statement/Coupon(s)
Current Year Pay Stub and or Profit & Loss Statement(s)
Federal and or State Tax Notices
Last Years federal tax return(s)
Credit Card Statements
Last year W-2 statement(s)
Any lien or judgment
One Bank statement reflecting any cash assets
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P. O. Box 3624 Huntington Beach, CA 92605 800-620-9204 [email protected]
Today’s date:__________
Please identify any mortgages that are in your name: Attach additional sheet if necessary Property address
Lender Name
Loan Balance
Monthly Payment
Interest Rate
Current Market Value
Check if past due
________________________________________________________________________________________
Please indicate goal with home: Owner Occupied Property address
Lender Name
Must Save my home
Loan Balance
Monthly Payment
Have you applied for loan Modification? Status of loan modification request?
Interest Rate
Need time to sell Current Market Value
Check if past due
Tried myself and or
Third Party
Declined
Approved
Tax returns: Year Taxes Filed?
Individual /joint?
If not, why not
Spouse filed tax returns?
If not, why not?
2015 2014 2013
Amount past due with IRS:$ ________________ State:$________________ NOTES_______________________________________________________________________________ © C o p y r i g h t 2 0 0 8 NativeAmericanTIO.org i s a 5 0 1 ( c ) 3 n o t f o r p r o f i t v2.5-2009 PRIVATE & CONFIDENTIAL INFO. 2 | Page
Today’s date:__________
P. O. Box 3624 Huntington Beach, CA 92605 800-620-9204 [email protected]
Credit Cards, Medical Bills, Judgments, and other debts owed: Name of Creditor
Total Balance
Minimum Payment Req.
Recent activity: During the last 60 days, have you done any of the following
Yes/No
Name of lender/transferee
Amount borrowed within the last 6 months
Used credit cards Taken cash advances Taken out any new loans
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Today’s date:__________
Monthly Expenses
Income
Provider of Services
Borrower
$
Rent/Mortgage
Employment Status
$
2nd Mortgage
Monthly Gross
$
$
Property Taxes
Monthly Net Average Payroll Deductions
$
$
Homeowner's/Renter's Ins.
$
$
HOA
Co Borrower
$
Electricity
Employment Status
$
Gas
Monthly Gross
$
$
Water/Trash/Sewer
Monthly Net Average Payroll Deductions
$
$
Cable/Satellite TV
$
$
Internet
$
Home Phone
$
Cell Phones
Other Income
Total Net
Car Loans Year/Make/ Model
©
P. O. Box 3624 Huntington Beach, CA 92605 800-620-9204 [email protected]
C o p y r i g h t
2 0 0 8
Fair Market Value
Balance
$
Gasoline
$
Car Payment 1
$
Car Payment 2
$
Car Payment 3
$
Car Insurance
$
Medical Insurance
$
Monthly Medical Expense
$
$
$
Life Insurance
$
$
$
Household Expense
$
$
$
Food
$
$
$
Other →___________
$
Other →___________
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Today’s date:__________
P. O. Box 3624 Huntington Beach, CA 92605 800-620-9204 [email protected]
Please identify any active bank accounts you own: Name of bank
Checking/ Savings?
In whose name?
Current balance
Any other loans or credit cards with this lender?
Please identify any pension, 401(k)or profit-sharing programs in which you participate: Name of financial institution
Type of plan
In whose name
Are you still contributing?
Current balance
Any loans against this plan?
Please identify any other assets that you own: Asset
Current Fair Market Value
Expected changes in income: Describe when & why: ________________________________________________________________________________________ ________________________________________________________________________________________ ________________________________________________________________________________________ ©
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Today’s date:__________
Have you pulled your free credit report within the last 12 months?:
P. O. Box 3624 Huntington Beach, CA 92605 800-620-9204 [email protected]
Yes | No
How would you rate your credit rating from 1 to 10, 10 being perfect: ___________ Previous Bankruptcies: Please list any prior bankruptcies: Where you filed
Chapter
Date Filed
Discharge? y/n
Children & Other Dependents Living in the Household Name
Age
Relationship
Lives with you?
Owe or Paid Child Support/Contribution
____________________________________________ Client Signature
___________________________ Date
____________________________________________ Client Signature
___________________________ Date
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6 | Page
P. O. Box 3624 Huntington Beach, CA 92605 800-620-9204 [email protected]
Your Name :______________________________ Date of Birth:___________________ Your address:___________________________________________ Apt. #:_____ City:
State:
Hm phone:
Zip:
Rent Own
County:___________________________________
_____ Wk phone:
___ Mobile: _________________ ______
E-Mail address:____________________________________________________________________________ Spouses Name :_____________________________ Date of Birth:_________________ Spouses address (if different from your own:_____________________________________________________ City:_________________ State:_____ Zip:____________ County:___________________________________ Home phone:____________ Work phone:________________ Mobile:_______________________________ E-Mail address:____________________________________________________________________________ If you have lived in your home for less than 1 year, please list your previous address: Address:_________________________________________ City:___________________________________ State:___________ Zip:________________ County:_____________________________________________ “NOTE YOUR IMMEDIATE GOALS” __________________________________________________________________________________________ __________________________________________________________________________________________ __________________________________________________________________________________________ __________________________________________________________________________________________ ____________________________________________________________________________________
Please fax the below listed information: Mortgage Statement/Coupon(s)
Current Year Pay Stub and or Profit & Loss Statement(s)
Federal and or State Tax Notices
Last Years federal tax return(s)
Credit Card Statements
Last year W-2 statement(s)
Any lien or judgment
One Bank statement reflecting any cash assets
©
C o p y r i g h t
2 0 0 8
NativeAmericanTIO.org
i s
a
5 0 1 ( c ) 3
n o t
f o r
p r o f i t v2.5-2009 PRIVATE & CONFIDENTIAL INFO.
1 | Page
P. O. Box 3624 Huntington Beach, CA 92605 800-620-9204 [email protected]
Today’s date:__________
Please identify any mortgages that are in your name: Attach additional sheet if necessary Property address
Lender Name
Loan Balance
Monthly Payment
Interest Rate
Current Market Value
Check if past due
________________________________________________________________________________________
Please indicate goal with home: Owner Occupied Property address
Lender Name
Must Save my home
Loan Balance
Monthly Payment
Have you applied for loan Modification? Status of loan modification request?
Interest Rate
Need time to sell Current Market Value
Check if past due
Tried myself and or
Third Party
Declined
Approved
Tax returns: Year Taxes Filed?
Individual /joint?
If not, why not
Spouse filed tax returns?
If not, why not?
2015 2014 2013
Amount past due with IRS:$ ________________ State:$________________ NOTES_______________________________________________________________________________ © C o p y r i g h t 2 0 0 8 NativeAmericanTIO.org i s a 5 0 1 ( c ) 3 n o t f o r p r o f i t v2.5-2009 PRIVATE & CONFIDENTIAL INFO. 2 | Page
Today’s date:__________
P. O. Box 3624 Huntington Beach, CA 92605 800-620-9204 [email protected]
Credit Cards, Medical Bills, Judgments, and other debts owed: Name of Creditor
Total Balance
Minimum Payment Req.
Recent activity: During the last 60 days, have you done any of the following
Yes/No
Name of lender/transferee
Amount borrowed within the last 6 months
Used credit cards Taken cash advances Taken out any new loans
©
C o p y r i g h t
2 0 0 8
NativeAmericanTIO.org
i s
a
5 0 1 ( c ) 3
n o t
f o r
p r o f i t v2.5-2009 PRIVATE & CONFIDENTIAL INFO.
3 | Page
Today’s date:__________
Monthly Expenses
Income
Provider of Services
Borrower
$
Rent/Mortgage
Employment Status
$
2nd Mortgage
Monthly Gross
$
$
Property Taxes
Monthly Net Average Payroll Deductions
$
$
Homeowner's/Renter's Ins.
$
$
HOA
Co Borrower
$
Electricity
Employment Status
$
Gas
Monthly Gross
$
$
Water/Trash/Sewer
Monthly Net Average Payroll Deductions
$
$
Cable/Satellite TV
$
$
Internet
$
Home Phone
$
Cell Phones
Other Income
Total Net
Car Loans Year/Make/ Model
©
P. O. Box 3624 Huntington Beach, CA 92605 800-620-9204 [email protected]
C o p y r i g h t
2 0 0 8
Fair Market Value
Balance
$
Gasoline
$
Car Payment 1
$
Car Payment 2
$
Car Payment 3
$
Car Insurance
$
Medical Insurance
$
Monthly Medical Expense
$
$
$
Life Insurance
$
$
$
Household Expense
$
$
$
Food
$
$
$
Other →___________
$
Other →___________
NativeAmericanTIO.org
i s
a
5 0 1 ( c ) 3
n o t
f o r
p r o f i t v2.5-2009 PRIVATE & CONFIDENTIAL INFO.
4 | Page
Today’s date:__________
P. O. Box 3624 Huntington Beach, CA 92605 800-620-9204 [email protected]
Please identify any active bank accounts you own: Name of bank
Checking/ Savings?
In whose name?
Current balance
Any other loans or credit cards with this lender?
Please identify any pension, 401(k)or profit-sharing programs in which you participate: Name of financial institution
Type of plan
In whose name
Are you still contributing?
Current balance
Any loans against this plan?
Please identify any other assets that you own: Asset
Current Fair Market Value
Expected changes in income: Describe when & why: ________________________________________________________________________________________ ________________________________________________________________________________________ ________________________________________________________________________________________ ©
C o p y r i g h t
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5 0 1 ( c ) 3
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p r o f i t v2.5-2009 PRIVATE & CONFIDENTIAL INFO.
5 | Page
Today’s date:__________
Have you pulled your free credit report within the last 12 months?:
P. O. Box 3624 Huntington Beach, CA 92605 800-620-9204 [email protected]
Yes | No
How would you rate your credit rating from 1 to 10, 10 being perfect: ___________ Previous Bankruptcies: Please list any prior bankruptcies: Where you filed
Chapter
Date Filed
Discharge? y/n
Children & Other Dependents Living in the Household Name
Age
Relationship
Lives with you?
Owe or Paid Child Support/Contribution
____________________________________________ Client Signature
___________________________ Date
____________________________________________ Client Signature
___________________________ Date
©
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6 | Page
