Your Name *
Date *
Email *
Phone Number *
Have you already scheduled your FREE INITIAL CONSULTATION? * Yes No
Would you like Mr. Adams to call you? * Yes No
Have you FILED a previous BANKRUPTCY within the last 8 yrs? * Yes No
If so, when?
Are you behind on your vehicles and/or home? * Yes No
Do you DESIRE TO KEEP YOUR PROPERTIES? Yes No
Do you have LARGE VALUE above debt in PROPERTIES YOU OWN? (such as mobile homes, motorcycles, stocks, bonds or land?) * Yes No
Value $
Have you had a lawsuit filed against you? * Yes No
Has the sheriff served you with papers? Yes No
What is your average Gross Income Monthly? $ *
What is your SPOUSE Gross Income Monthly? $
Do you have children under the age of 20 yrs? Yes No
If yes, how many?
Have your wages/bank accounts been GARNISHED? (money taken out of your paycheck/checking acc. for a bill) * Yes No
If you have a house, do you want to KEEP your HOME? * Yes No
Do you have a 1st Mortgage? Yes No
Are you in foreclosure? Yes No
How many payments are you behind?
What is your normal monthly payment? $
What is your interest rate?
Is it a fixed rate? Yes No
If you have a 2nd house, do you want to KEEP your HOME Yes No
Do you have a 2nd Mortgage? Yes No
Are you in foreclosure? Yes No
How many payments are you behind?
What is your normal monthly payment? $
What is your interest rate?
Is it a fixed rate? Yes No
Do you OWE on Vehicle(s)? * Yes No
1st Vehicle Make
1st Vehicle Model
1st Vehicle Year
What is your normal monthly payment? $
Purchase date?
How much longer do you owe?
What is your interest rate?
Do you OWE on a 2nd Vehicle? * Yes No
2nd Vehicle Make
2nd Vehicle Model
2nd Vehicle Year
What is your normal monthly payment? $
Purchase date?
How much longer do you owe?
What is your interest rate?
Are any of these debts JOINTLY OWED OR COSIGNED DEBTS? * Yes No
Do you have any additional Debt? * Yes No
# of Credit Cards?
Estimated Amount Owed $
# of Medical Bills
Estimated Amount Owed $
Value City, HH Gregg, Best Buy, Jewelry Store, etc
Any Additional Information:
