CONSULTATION DATE. We are a debt relief agency. We help people file for bankruptcy under the bankruptcy code.** Legal. Name

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1 CONSULTATION DATE We are a debt relief agency. We help people file for bankruptcy under the bankruptcy code.** Legal Name: First Middle Last Social Security No. Spouse s Name: First Middle Last SSN#( if joint case) Primary Residence Address: Street Address Apt. # City Zip Date Of Birth-Debtor City Of Birth County of Residence: How Long at current address Prior Address(es) for last 3 years: / / Home Phone: Work Phone: Cell Phone: Spouse Work #: Address: Address(spouse) Other Names Used by you in the last ten years: Your highest education level: (circle one) high school, college, graduate school, professional degree, other Mothers maiden name: (If joint case)spouses mother s maiden Name Marital Status: Married Divorced Single Widow Separated List names and ages of children and any other dependants living in household: Age Age Age Age Your Current Employer: / Name Address Position: Length of employment: Spouses Current Employer: / Name Address Position: Length of employment:

2 Emergency Contact: Name Address Relationship to you: Phone No: How were you referred to our office? AT&T Yellow Pages Attorney Referral Friend Relative TV Commercial What is your reason for seeking bankruptcy relief? (circle one) Stop foreclosure, garnishment, Repossession, pending lawsuits, excessive credit card debt, delinquent taxes, delinquent child support, other reason: describe Have you been contacted by an attorney regarding FORECLOSURE? If yes, what is the scheduled foreclosure date? Are you being threatened with REPOSSESSION? If yes, do you have full coverage insurance? Are you presently involved in any lawsuits?(i.e. personal injury, workers comp, civil matters) If yes, please give date of incident, status of case, name & tele. no of Attorney representing you: Date of Accident Status of Case:(circle one) Pending, About to Settle, Settled, Dismissed Attorney handling Case: Tele. No Have you filed all tax returns for the past two (2) years? If no, what is your reason for not filing? What chapter would you like to file? Chapter 13 Chapter 7 PRIOR BANKRUPTCIES Chapter 7 or 13 Location of Filing: Case Number(if known): Date Filed: Was case discharged or dismissed?

3 PENDING/ACTIVE BANKRUPTCY (filed by spouse, partner or affiliate) Chapter 7 or 13 Filers name: Relationship to you Location of Filing: Case Number(if known) Date Filed: INCOME List your Gross income for the following years: (year to date) List your Gross Income for the last six (6) months: Do you expect a salary increase within the next six months? List any additional sources of Monthly Income: Part Time Job Child Support Alimony

4 Social Security $ Pension Disability TANF Roommate/ Family Contribution $ Other $ ** If you have other sources of monthly income, please be prepared to provide proof of the additional income** MONTHLY EXPENDITURES List your average Monthly household expenses: Rent/Mortgage Are Taxes and Insurance Included? yes no Homeowners Insurance Property Taxes Electric Gas Water Phone Cable Cell Phone Internet Alarm Sanitation Home Repairs Food Clothing Laundry/Dry Cleaning Medical/Dental Transportation/Gas Car Insurance Car Payment $

5 Lease Payments Child Support Alimony Child Care Credit Cards Tithes Care to Elderly Parents 401K Savings 401K Loans Homeowners Assoc Fees Timeshare Fees Student Loans Other Expenses If applicable, list average monthly business expenses: Business Name: Business Address: Type of Business: Average Gross Monthly Income Regular Monthly Businesss Expenses: $ /rent $ /insurance $ /salaries $ $ /supplies $ $ /fuel *It may be necessary for you to provide proof of your monthly business expenses* LIABILITIES (debts you owe) ****Please provide a current credit report, a list of your monthly bills or the most recent monthly statements including the name, address, account number and balance owed to each creditor****

6 Unsecured debts: (no collateral attached) Please estimate how much unsecured debt you have. Credit Cards $ Medical Bills Signature Loans Student loans $ $ $ Are your student loans in deferment or forbearance? yes no If yes, when will the deferment or forbearance period end? Credit Union Loans $ Other $ Secured Debts: (collateral attached) Please give approximate balances owed on the following: 1 st Mortgage(residence)Loan balance$ /Mo. Pymt $ # mos behind Does the mo. payment include property taxes and insurance? yes no If no, please give yearly amount: property taxes $ homeowners ins $ 2 nd Mortgage(residence) Loan balance $ /Mo. Pymt $ # mos behind 1 st Mortgage(rental property)loan balance $ /Mo.Pymt $ # mos behind 2 nd Mortgage(rental property)loan balance $ /Mo. Pymt $ # mos behind Automobile(1)Loan Balance Mo. Pymt $ # mos behind Automobile(2)Loan Balance Mo. Pymt $ # mos behind Furniture Loan Balance Mo. Pymt $ # mos behind Home Improvement Loan/ Loan Balance $ /Mo. Pymt $ # mos behind Title Loans-Loan Balance /Mo. Pymt $ # mos behind Property Taxes (Amount Owed) / Mo. Pymt $ # mos behind Association Fees(Amount Owed) / Mo. Pymt $ # mos behind Priority Debts: (taxes, child support) Federal Taxes-Amount Owed /years owed State Taxes(State of ) Amount Owed $ /years owed Child Support- Arrears Amount $ /Mo. Pymt $ # mos. behind Please give custodial parents name, address & contact no: Lease Obligations: (rental or lease agreements)

7 Auto Lease Balance /expiration date Mo. Pymt $ Furniture Lease Balance $ /expiration date Mo. Pymt $ Other Lease Balance /expiration date Mo. Pymt $ STATEMENT OF FINANCIAL AFFAIRS ***Please answer all questions. If a question does not pertain to you, please write N/A in the space provided.*** 1. List your gross income from employment or operation of a business for the following years: 2009-$ source: 2008-$ source: 2007-$ source: 2. List your gross income from a source other than employment or operation of a business for the following years: 2009-$ source: 2008-$ source: 2007-$ source: Attach pay stubs received In the past sixty (60) days. Attach copies of your tax Returns for the past two years. Indicate that amount and source of Income for this year-to-date, last year and two years ago. Did you sell anything, receive any benefits such as unemployment insurance, or have any gambling winnings? Indicate the amount and source of income for this year to date, last year and two years ago. 3. Have you paid any creditors family members or any other person a lump sum payment of $ or more within the last (1) year? 4. List all business that you have owned or been affiliated with during the last two (2) years. Give creditor, family members or friends name and address, date of payment, amount paid and amount still owed. Give name, address, type of business, dates of operation. 4.(a) If you are a business owner, have you paid or transferred to any creditors a lump sum payment of $ or more in the last (1) year? 5. Have you received a lump sum payment of $ or more from any source in the last two (2) years? (i.e. SSI Benefits, Personal Injury Settlement, Workers Comp. Settlement, Disability, Inheritance, etc.) Give creditors name, address date of payment, amount paid and amount still owed. Name source of payment(s), amount received, and date of payment(s). 6. (a) List all suits and administrative proceedings, executions, garnishments and attachments to which you were a party within the last year. Give case name, case number, nature of proceeding, court and location, and status of case. (b) Describe any property that has been attached, garnished, foreclosed or repossessed in the last year. Give name and address of person who seized property, date, description and value of property. 7. List all gifts of more than $200 to family members or charitable contributions of more than $100 Indicate the name and address of

8 per recipient made within one year. (e.g. tithes/offerings) recipient, relationship to debtor, if any, date of gift and description and value of gift. 8. List all losses from fire, theft, other casualty or gambling within 1 year. Indicate the description and value of property, description of circumstances and whether the loss was covered in whole or in part by insurance and the date of loss. 9. List all payments made by debtor or for the debtor to any persons, including attorneys for consultation regarding debt consolidation, bankruptcy relief or preparation of a bankruptcy petition within 1 year. Indicate name and address of payee, date of payment, name of payer if other than debtor and amount paid. 10. Disclose the sale or transfer of your interest in any property within 2 years. (i.e. real property, automobile, stocks, retirement plans, etc) Indicate name and address of transferee, relationship to you, date and description of transferred property and value received. 11. Disclose the transfer of any property within 10 years to a self-settled trust or similar device of which you are the beneficiary. 12. List all financial accounts and instruments in your name which were closed, sold or otherwise transferred within 1 year. Include checking, savings, CD s, shares and share accounts held in banks, credit unions, pension funds, cooperatives, associations, brokerage houses and other financial institutions. Indicate name of the trust or other device, date(s) of transfer(s), amount of money or description and value of property or your interest in the property. Indicate the name and address of the institution, type and number of account and amount of final balance, and the amount and date of sale or closing. 13. List all safe deposit or other box or depository you have or had securities, cash or other valuables within 1 year. 14. List all property which has been in the hands of a custodian, receiver or court-appointed official within 1 year. Indicate the name and address of bank or other depository, names and addresses of those with access to box or depository, description of contents and date of transfer or surrender if any Indicate name and address of custodian, name and location of court, case title and number, date of order and description and value of property. 15. List all property owned by another person that you hold or control.(i.e. use of another s vehicle) Indicate name and address of owner, description and value of property and the location of the property. 16. Disclose all prior addresses within the last 3 years. Indicate address, name used and dates of occupancy. 17. If you reside or resided in a community property state, commonwealth or territory (including Alaska, Arizona, California, Idaho, Louisiana, Nevada, New Mexico, Puerto Rico, Texas, Washington or Wisconsin) within the last 8 years, identify the name of your spouse and any former spouse who resides or resided with you in the community property state. Indicate spouse or former spouses name. 18. Disclose the name and address of any site or property you own or owned where you were notified by a governmental unit that it may be liable of violating an Environmental Law or that Hazardous Material may exist on the property Indicate name and address, name and address of governmental unit, date of notice, and environmental

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