Bankruptcy Evaluation

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We're here to do everything we can to help.

Everything on the form is confidential.

Do your best to fill out the form, but don't worry if you don't have exact numbers.  This is an evaluation form only.  After our bankruptcy counselor has looked it over, which won't take long, we'll call you and let you know how we can help.

 
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What kind of bills do you have

Just check any boxes that apply

 Less than $5,000
 $5,000 - $10,000
 $10,000 - $15,000
 $15,000 - $20,000
 $20,000 - $30,000
 $30,000 - $40,000
 $40,000 - $50,000
 over $50,000

About Your Home

 Yes   No 

 Yes   No 

Your vehicles

Vehicle 1

 Yes   No 

Vehicle 2

 Yes   No 

Other Assets

What other property of significant value do you own?  A business, jewelry, stocks, bonds, other land property, etc

Your Income

 Yes   No 

 Every Week   Every 2 Weeks   Twice a Month   Once a Month 

Other Income - Check all that apply

Your Spouse's Income (optional)

 Every Week   Every 2 Weeks   Twice a Month   Once a Month 

Just a couple of last questions

 Yes   No 


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