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Client Information Worksheets
Debtor Spouse
Full Name:__________________________ _______________________________________
Filedbefore? Yes_________ No__________ When:____________ Where:______________________
Number of Dependants living with you____________ Household size____________
Employer:_____________________________ ________________________________
How long have you lived in NC?________________ Phone No:______________________
What goal do you want to accomplich in bankruptcy?
Save a house__________ Save a car___________ Start over after releasing property_______
Get rid of overwhelming unsecured debt__________ Other_________________________
| Average Monthly Income |
Debtor |
Spouse |
| Gross wages, salary, commisions |
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| Estmated monthly overtime |
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| Subtotal of income |
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| Payroll Deductions: |
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| Payroll taxes & social security |
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| Insurance |
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| Union Dues |
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| Other (SPECIFY) |
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| Subtotal of Deductions |
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| Other income: |
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| Regular income from business,farm or profession |
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| Income from real estate property |
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| Interests & dividends |
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| Alimony or support payments payable to debtor or dependents |
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| Social security or other governments benefits(SPECIFY) |
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| Pension and/or retirement |
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| Other income (SPECIFY) |
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| Subtotal of other income |
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| TOTALCOMBINEDMONTHLYINCOME |
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Monthly Expenses for Family
| Rent or Mortgage Payment |
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Property taxes included in payment
Yes No |
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Property Insurance included in payment
Yes No |
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| Electric/Heating Fuel |
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Water & Sewer |
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| Telephone |
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| Cell Phone |
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| Home Maintainance |
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| Food(include lunches) |
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| Clothing |
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| Laundry & Dry Cleaning |
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| Medical & Dental |
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| Transportation (gas + oil changes) |
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Recreation (newspaper,magazines,entertainment,club,etc.) |
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| Charitable Contribution |
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| Insurance (not deducted from wages or included in mortgage) |
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| Homeowners or Renters Insurance |
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| Life Insurance |
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| Health Insurance |
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| Auto Insurance |
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| Other (SPECIFY) |
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| Taxes (not deducted from wages or included in mortgage) (SPECIFY) |
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Alimony, support paid to others (SPECIFY) |
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| Regular expenses for operation of business (attach statement) |
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| Other (SPECIFY) |
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| Child Care |
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| Cable |
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| Internet Service |
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Total Monthly Expenses
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HOUSING
Renters: Is your rent current? _______ If not, how many months are you behind ?______
HOMEOWNERS: What is the tax value of your house? ___________ Fair market value___________ Loan Amount_______ How many mortgages or equity lines are currently on the house? ___________________
1. First Mortgage Co. _____________________ Loan amount__________________
Amt. of monthly payment:_______Are you Behind? Yes___ No___If so, how many months? __________
2. Second Mortgage Co. _____________________ Loan amount__________________
Amt. of monthly payment:_____ Are you Behind? Yes____ No___If so, how many months? ____________
Do you own any other real estate? Yes________ No________
Moblie Home Owners: Make/Model:_____________________________ Year______________________ House attached to Land: Yes____ No_____ Do you own the land: Yes____ No_____ Tax Value:____________ Home in park, Monthly rent_____
1. First Mortgage Co. _____________________ Loan amount__________________
Amt. of monthly payment:_____________Are you Behind? Yes______ No______ If so, how many months? _______
2. Second Mortgage Co. _____________________ Loan amount__________________
Amt. of monthly payment:_____________Are you Behind? Yes______ No______ If so, how many months? ______
VEHICLES
List All cars, trucks, motorcycles, boats, trailers owned by any family member.Are any leased?
1. Vehicle Year____ Make/Model _____________ Date purchased_______ Value________
Monthly payment___________ No. of Months behind________ Loan payoff amt:_______
2. Vehicle Year____ Make/Model _____________ Date purchased_______ Value________
Monthly payment___________ No. of Months behind________ Loan payoff amt:_______
3. Vehicle Year____ Make/Model _____________ Date purchased_______ Value________
Monthly payment___________ No. of Months behind________ Loan payoff amt:_______ Which vehicles are leased?______________________________________________
Credit Card, Personal Loans, Medical, and Other Unsecured Debt
Major Credit Card Debts (Visa American Express, Mastercard, Discover)
CARD NAME AMOUNT OWED
__________________________________ ________________________
__________________________________ ________________________
__________________________________ ________________________
__________________________________ ________________________
__________________________________ ________________________
__________________________________ ________________________
__________________________________ ________________________
__________________________________ ________________________
__________________________________ ________________________
__________________________________ ________________________
__________________________________ ________________________
Total ________________________
HAVE YOU USED ANY CREDIT CARDS WITHIN THE LAST 3 MONTHS? If so, put a checkmark by each one used.
Personal Loans (Citifinancial, American General, Wells Fargo, etc.) Please put the creditors name and the amount owed
__________________________________ ________________________
__________________________________ ________________________
__________________________________ ________________________
Unpaid Medical bills
__________________________________ ________________________
__________________________________ ________________________
__________________________________ ________________________
__________________________________ ________________________
unpaid bank overdraft or cash reserve loan ________________________
Repossession: car, boat, 4-wheeler, etc. ________________________
Total Dischargeable Debt ________________________
NON DISCHARGABLE DEBT
TAXES: IRS amount ____________ Years___________ State amount _____________ Year____________ Real Estate Tax ______________ Personal Property Tax _____________________ Student Loans _________________________
LAST SIX MONTHS OF GROSS INCOME
Before Taxes and Deductions
***YOU HAVE TO FILL THIS SECTION OUT FOR YOUR CONSULTATION***
Husband Wife
Month Gross Month Gross
**Please make sure that you put the month, and gross amount(before taxes are taken out) on the lines above. Please bring a print out of last six months income from employer or six months of pay stubs for verification purposes only.**
IMPORTANT
Filing bankruptcy is a very important decision for you and your spouse to make your full attention during the consultation will be necessary so you can make the best decision for your situation.
We love babes and children, but they can be distracting and impatient and you will need all your concentration on what Ms. Davis tells you. If at all possible please find someone to keep the children. The consultation is usually about 1 hour long.
Please do not have your cell phone during the consultation.
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