Date
How did you hear about us?
Do you have an appointment with our office?
Name
First, Middle, Last
Address
City, State, Zip
Employer/Position
Home Phone
Work Phone
Cell Phone
E-mail
Have you filed bankrupcty in the past?
If so when?
Have you lived in Hawaii for 2 years?
If no, where did you live before and for how long?
Marital Status?
What is your approximate take home income per month (not per pay period) after deductions for taxes, social security, and insurance?
(Please include spouses income whether filing a case with you or not)
Are there any special deductions out of your pay?
How much and for what?
What are your approximate expenses per month for the following items?
Mortgage/Rent
2nd Mortgage
3rd Mortgage
Maintenance Fees
Medical
Electrical
Laundry
Water
Hair Cuts
Gas
Cable
Telephone
Gas
Vehicles
If more than one, combine them
Car Maintenance
Car Insurance
Child Support
Recreation
Pets
Other
Mortgages and Other House Related Debts
Name of Creditor, Balance and Real Estate Value
Separate by commas
Name of Creditor, Balance and Real Estate Value
Separate by commas
Name of Creditor, Balance and Real Estate Value
Separate by commas
Name of Creditor, Balance and Real Estate Value
Separate by commas
CAR DEBTS
Name of Creditor, Balance, type & year of car
Name of Creditor, Balance, type & year of car
Name of Creditor, Balance, type & year of car
CREDIT CARDS
Type and Total Balance Owed
Type and Total Balance Owed
Type and Total Balance Owed
Type and Total Balance Owed
SINGATURE LOANS with collateral
Creditor and Balance
Creditor and Balance
Creditor and Balance
SIGNATURE LOANS without collateral
Creditor and Balance
Creditor and Balance
Creditor and Balance
MEDICAL BILLS
Creditor and Balance
Creditor and Balance
STUDENT LOANS
Creditor and Balance
Creditor and Balance
OTHER LOANS
Creditor and Balance
Creditor and Balance
Do you own real estate, a house, a condominium? Yes/No; if yes, what is the current fair market value of your real property?
i. Do you own any of the personal property listed below:
Checking account?
If yes what is the balance?
Savings account?
If yes what is the balance?
Interest in other companies, stocks, bonds, other financial investments?
If yes what is the balance?
401(k), IRA, or other retirement account?
If yes what is the balance?
If you currently own a business, what type of business?
Are you paying or receiving child support or alimony payments?
Paying – amount:
Receiving – amount:
Do you owe any taxes? (Federal taxes, State taxes, e.g., GE Tax, property taxes)? If yes, for what years and what kind of taxes?
Are you late or have missed payments for your house or car?
House & number of months
Car & number of months
Car & number of months
Are you currently involved in a law suit or other legal or administrative proceeding?
If yes what is the basis of the lawsuit?
Could you file a law suit at this time (e.g., following a car accident, worker’s compensation claim, etc.)
If yes explain.
Do you have student loans?
If yes, for what years? What type? Amounts?
Are you paying back any loans from family members?
If yes to whom and how much did you pay in the last 2 years?
Do you have any co-debtors, e.g., did anybody co-sign a promissory note (house, car), do you have joint credit card accounts, etc?
If yes list the dates and who co-signed?
ADDITIONAL INFORMATION.
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