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Your Name:
Date:
E-mail Address:
Your Phone Number:

Information

1. Have you already scheduled your FREE INITIAL CONSULTATION
  
2. Would you like Mr. Adams to call you?
  
3. Have you FILED a previous BANKRUPTCY within the last 8 yrs?
a. When
  
4. ARE YOU BEHIND ON YOUR VEHICLES AND/OR HOME?
a. Do you DESIRE TO KEEP YOUR PROPERTIES?
  
5. Do you have LARGE VALUE above debt in PROPERTIES YOU OWN? such as mobile homes, motorcycles, stocks, bonds or land?
a. Value $
  
6. Have you had a lawsuit filed against you?
a. Has the sheriff served you with papers?
  
7. What is your average Gross Income Monthly? $
a. What is your SPOUSE Gross Income Monthly? $

b. Do you have children under the age of 20 yrs?
c. If yes, how many?
  
8. Have your wages/bank accounts been GARNISHED? (money taken out of your paycheck/checking acc. for a bill)
  
9. If you have a house, do you want to KEEP your HOME?
a. Do you have a 1st Mortgage?
b. Are you in foreclosure?
c. How many payments
are you behind?

d. What is your normal monthly payment? $

e. What is your interest rate?

f. Is it a fixed rate?
  
10. If you have a house, do you want to KEEP your HOME
a. Do you have a 2nd Mortgage?
b. Are you in foreclosure?
c. How many payments
are you behind?

d. What is your normal monthly payment? $

e. What is your interest rate?
f. Is it a fixed rate?
  
11. Do you OWE on Vehicle(s)?
a. 1st Vehicle Make

b. 1st Vehicle Model

c. 1st Vehicle Year
d. What is your normal monthly payment? $

e. When purchased?
f. How much longer do you owe?
g. What is your interest rate?
  
12. Do you OWE on a 2nd Vehicle?
a. 2nd Vehicle Make

b. 2nd Vehicle Model
c. 2nd Vehicle Year
d. What is your normal monthly payment? $
e. When purchased?
f. How much longer do you owe?
g. What is your interest rate?
  
13. Are any of these debts JOINTLY OWED OR COSIGNED DEBTS?
  
14. Do you have any additonal Debt?
# of Credit Cards?

Estimated Amount Owed $
  
# of Medical Bills
Estimated Amount Owed $

  
Value City, HH Gregg, Best Buy, Jewelry Store, etc
  

Any

Additional

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