Evaluation Form

Contact Information
Name *:
Spouse's Name *:
Email *:
Address :
City *:
State *:
Zip *:
Cell Phone:
Home Phone:
Work Phone:
 
Preferred Contact : Home              Cell              Work
Debt
Please provide estimates of your debts for each ofr the categories listed below. You will be asked to provide more specific information after your initial consultation; therefore, it is understood that the figures you provide today may change prior to completing your legal documents
Child Support Arears :
Credit Card Debt (total) :
IRS Debts :
Judgements :
Medical Bills :
Other :
Payday Loans :
Personal Loans :
Student Loans :
Income
Tell us about your monthly income
Your Income (after taxes):
Spouse's Income (after taxes):
Social Security:
Retirement/Pension Income:
Other Income:
Assets
 
Do you own any real estate?: Yes              No             
If yes, are you behind on these payments?: Yes              No             
Do you own any vehicles?: Yes              No             
If yes, are you behind on these payments?: Yes              No