MARITAL STATUS:
FULL LEGAL NAME: SS#: DOB: //
SPOUSE LEGAL NAME: SS#: DOB: //
STREET ADDRESS: EMAIL:
CITY: ZIP: COUNTY: TEL#: --
NUMBER IN HOUSEHOLD: EVER FILED BANKRUPTCY BEFORE?: WHAT YEAR?: 7 or 13?:
ARE ANY OF YOUR HOUSES CURRENTLY IN FORECLOSURE?: DATE SET FOR FORCLOSURE: //
YOUR EMPLOYER: SPOUSE'S EMPLOYER:
WHAT IS YOUR GROSS INCOME SO FAR THIS YEAR?: $ SPOUSE: $
GROSS INCOME LAST YEAR?: $ SPOUSE: $
HAVE YOU LIVED AT YOUR CURRENT ADDRESS FOR MORE THAN TWO YEARS? IF NOT, THEN PLEASE LIST ALL ADDRESSES THAT YOU HAVE LIVED AT IN THE PAST THREE YEARS?
HAVE YOU FILED ALL OF YOUR TAX RETURNS WITHIN THE PAST FOUR YEARS?: FILED ON TIME?:
DO YOU OWE IRS?: GA DEPT. REV?: PROPERTY TAX?:
DO YOU PAY CHILD SUPPORT?: ARE YOU CURRENT?: HOW MUCH ARE YOU BEHIND?: $
DO YOU HAVE ANY LEASES OR RENT-TO-OWN CONTRACTS LIKE A RENT-A-CENTER OR CAR LEASE?:
NAME OF THE CREDITOR: WHAT IS THE COLLATERAL?:
WHAT IS THE PAYMENT?: $ WHEN DOES THE PAYMENT END?: //
HAS ANYONE ELSE SIGNED ON A DEBT WITH YOU OR YOU WITH THEM?:
IF SO, LIST THEIR NAME AND ADDRESS:
CREDITOR NAME:
DO YOU HAVE A STUDENT LOAN?: IF SO, HOW MUCH IS STILL OWED?: $ IS IT IN DEFERMENT?:
IN DEFAULT?: IF NOT, PAYMENT AMOUNT : $ WHEN WILL IT BE PAID IN FULL?: //
PLEASE GIVE A BRIEF DESCRIPTION INCLUDING ADDRESSES, AND THE VALUE, OF ANY REAL ESTATE IN WHICH YOU HAVE ANY INTEREST ( life estate, heir interest, and all other ownership interests )
PLEASE LIST ALL VEHICLES THAT ARE IN YOUR NAME:

(IN SPACE ABOVE LIST ALL CARS , MOTORCYCLES & ATV’S WHICH ARE TITLED IN YOUR NAME ,THE NAME OF THE CREDITOR IF THERE IS A BALANCE , AND THE ESTIMATED VALUE OF EACH SUCH VEHICLE )
BANK BALANCE BANK BALANCE
CHECKING $ 401K $
CREDIT UNION $ OTHER RETIREMENT $
SAVINGS $ CASH $
IRA $ OTHER $
SAFETY DEPOSIT BOX $ OTHER $
HOUSEHOLD GOODS: PLEASE ESTIMATE THE VALUE OF THE FOLLOWING ASSETS IF SOLD AT YARD-SALE:

BEDROOM FURNITURE: $ LIVING ROOM/DEN: $ DINING ROOM: $ KITCHEN: $ TV'S: $
VCR/DVD: $ STEREOS: $ WASHER/DRYER: $ YARD EQUIP: $ COMPUTER EQUIP: $
CLOTHING: $ JEWELRY: $ HOBBY EQUIP: $ PHOTO EQUIP: $
INCOME INFORMATION
HOW OFTEN DO YOU GET PAID?: YOUR SPOUSE?:
WHAT IS YOUR AVERAGE GROSS INCOME (before deductions ) EACH PAY PERIOD?: $ SPOUSE?: $
AVERAGE NET INCOME (after taxes , insurance , and all deductions) EACH PAY PERIOD?: $ SPOUSE?: $
DO YOU HAVE ANY SOURCE OF INCOME OTHER THAN YOUR JOB?
IF SO, PLEASE LIST ALL SOURCES SUCH AS SELF-EMPLOYMENT, PART-TIME INCOME, RENTAL INCOME , RETIREMENT, SOCIAL SECURITY, DISABILITY, WORKERS COMPENSATION, VETERAN=S BENEFITS, FOOD STAMPS, WELFARE, CHILD SUPPORT, AFDC, ALIMONY OR ANY OTHER:
PLEASE LIST YOUR ESTIMATED MONTHLY LIVING EXPENSES:

$ Rent/Mortgage $ Food
  - Does this include tax?: $ Clothing
  - Does this include home insurance?: $ Medical
$ Electricity $ Gas (for car)
$ WATER $ CAR INSURANCE
$ PHONE/CELL $ HEALTH INSURANCE (NOT DEDUCTED FROM PAY)
$ CABLE/SATELLITE/INTERNET $ LIFE INSURANCE (NOT DECUTED FROM PAY)
$ GAS (FOR HOUSE) $ CHURCH CONTRIBUTION
$ OTHER UTILITIES/EXPENSES $ TAXES (PROPERTY TAX, CAR TAGS, TAX)
$ ASSITANCE TO ELDERLY OR INFIRM FAMILY MEMBER $ CHILD SUPPORT/ALIMONY
LIST YOUR TEN LARGEST CREDITORS AND IF THERE IS COLLATERAL FOR THE DEBT PLEASE INDICATE:

1. NAME: BALANCE: $ COLLATERAL: VALUE: $
2. NAME: BALANCE: $ COLLATERAL: VALUE: $
3. NAME: BALANCE: $ COLLATERAL: VALUE: $
4. NAME: BALANCE: $ COLLATERAL: VALUE: $
5. NAME: BALANCE: $ COLLATERAL: VALUE: $
6. NAME: BALANCE: $ COLLATERAL: VALUE: $
7. NAME: BALANCE: $ COLLATERAL: VALUE: $
8. NAME: BALANCE: $ COLLATERAL: VALUE: $
9. NAME: BALANCE: $ COLLATERAL: VALUE: $
10. NAME: BALANCE: $ COLLATERAL: VALUE: $
THANK YOU FOR COMPLETING OUR ONLINE QUESTIONNAIRE. WE WILL EVALUATE YOUR FINANCIAL SITUATION AND CONTACT YOU WITHIN 24 HOURS FOR A FREE CONSULTATION AND A DISCUSSION OF THE LEGAL OPTIONS AVAILABLE TO YOU. WE APPRECIATE THE OPPORTUNITY TO ASSIST YOU IN THIS VERY IMPORTANT MATTER.


SINCERELY,

Ken Fuller


ATTORNEY AT LAW