HAMMOND & HAMMOND, P.C. 122 SOUTH MAIN STREET * JONESBORO, GA / Fax allenhammond@mindspring.

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1 HAMMOND & HAMMOND, P.C. 122 SOUTH MAIN STREET * JONESBORO, GA / Fax allenhammo@mispring.com Your Full Legal Name: Social Security Number: Date of Birth Spouse s Full Legal Name: Social Security Number: Date of Birth If you are a Jr./Sr./Etc. ~or~ had other names in the last 8 years, list above. Name(s) a address need to match with your drivers license a SS card. Address: Street: City: County: ZIP Telephone Number Where we can reach you: Have you ever filed chapter 7 or 13 before? Yes, No Depeents that live with you: 1. Age: 2. Age: 3. Age: MORTGAGE INFORMATION (for address listed above): Do you own or are you buying a house or any la? Are you current? If not, how many months behi: st 1 Lienholder: Payoff amount: $ Monthly Pmt $ Are you up to date on payments? Yes No

2 2 Lienholder: Payoff amount $ Monthly Pmts $ Are you up to date on 2 lien payments? Yes No Do you have a Homeowners Association: Do you own any other real estate? Yes No Do you own a timeshare? Yes No EMPLOYMENT INFORMATION: Your Employment information: Job description: How long employed: Name of employer: How often are you paid? Do you have other income besides your job? Yes No Social Security Yes No Food Assistance Yes No Support/Alimony Yes No Unemployment Comp. Yes No Spouse Employment information: Job description: How long employed: Name of employer: How often are you paid? Do you have other income besides your job? Yes No Social Security Yes No Food Assistance Yes No Support/Alimony Yes No Unemployment Comp. Yes No

3 TAX DEBT: Do you owe any money to the IRS? or State? Have you filed all returns? Yes No LEASES: Are you leasing or renting to own anything? Yes No (furniture, washer/dryer, tv s, etc) CO-SIGNERS: Are you a cosigner Yes No Has someone co signed with you Yes No MONTHLY EXPENSES: st (1 ) (2 ) Mortgage/Rent $ + Homeowners Assoc $ Does your mortgage include taxes a insurance? Yes No If not, how much is your property taxes monthly: $ If not, how much is your property insurance monthly: $ Gas & Elec. $ Medicines $ Water $ Food $ Telephone (hm) $ Maint-home $ Telephone (cell) $ Clothing $ Cable & Internet $ Laury $ Garbage $ Renters Ins $ Alarm $ Gas for Car $ Car insurance $ Daycare $ Car payment $ Charitable $ 2 Car payment $ (Need name/add for Charitable Contributions) LIFE INSURANCE: Do you have life insurance Yes No Monthly premium $ STUDENT LOANS: Do you have a student loan Yes No Monthly payment $ IF SPOUSE NOT FILING WITH YOU: Does your spouse have any debts that are in their name alone? Yes No BANK INFORMATION: (Checking & Saving & any Credit Unions) Where do you bank?

4 ASSETS: (Please list the CURRENT DOLLAR VALUE, not a list of items) Household furniture/appliances/tvs Jewelry/Watches Do you collect anything of value? (coins, stamps, paintings, etc) IRA/401k/Pension: Do you have any type of retirement account? Yes No do you have a loan against your retirement account? Yes No VEHICLES: What year a type of motor vehicle do you own? IS YOUR NAME ON ANY OTHER PROPERTY ~OR~ BANK ACCOUNT: Is your name on any property that is owned jointly with any family member or other relative even if only for convenience? For example, is your name on your parent s bank account or the deed to their home even though you don t consider yourself to be one of the owners? (If the answer is yes, the atty needs to see a copy of bk stmt & the property records from online). PERSONAL INJURY/ETC. Have you been involved in any car accident, slip a fall, medical malpractice or other personal injury action which was or is peing or had occurred in the last 2 years? (If answer is yes, the atty needs to know the attorney s name/address who is representing you & the retainer agrmt ~&~ any monies $ you might receive.) Also if you have rec d any monies in the last 2 years from a settlement, we need a copy of that information. DO YOU EXPECT TO RECEIVE ANY MONIES FROM CAR ACCIDENT/ INHERITANCE/ DEBT OWED TO YOU/ETC:

5 CHILD SUPPORT OR DOMESTIC SUPPORT: Do you receive Child Support? Yes No Do you pay child Support? Yes No PRIOR ADDRESSES WITHIN THE LAST 3 YEARS: (List full address a dates you lived there) CASH ADVANCES OR CHARGING ON CREDIT CARDS: Have you taken a cash advance or charged on any credit card in the last 12 months? Yes No OPERATED A BUSINESS WITHIN THE LAST 6 YEARS: Yes No STATE OF GEORGIA: How long have you lived in the State of Georgia? GROSS INCOME: (Husba) This month $ Last month $ (Wife) $ $ YTD $ $ Last Year $ $ 2 years ago $ $ Please attach all pay stubs for the last 60 days a last year s tax return