:: LEGAL FORM CONSULTATION QUESTIONNAIRE ::

Select Your Desired Bankruptcy

Chapter 7   |   Chapter 11    |    Chapter 13

Please fill out the corresponding sections of this questionnaire and then Click the Submit Button:

Please note that we do adhere to utmost principles of ethical responsibility and confidentiality...

DISCLOSURE FROM NON-LAWYER:

...By submitting this form, you are agreeing that we have informed you that our consultants are experienced legal documentation/form consultants who are nonetheless "non-lawyers"; i.e., although we are authorized to assist you in different capacities with various forms that are either pre-approved or not pre-approved by the Florida Supreme Court (i.e., Rule 10-2.1(a) and (b) of the Rules Regulating the Florida Bar) and comparable rules of other states and Federal entities, we cannot represent you in court, or tell you how to testify in court, or tell you what your rights or remedies are. Our job is simply to assist you in properly filling out your legal forms to the extent authorized by the aforementioned rules.

-- Thank you so much for using our service!

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1) PERSONAL INFORMATION

First Name:                  Last Name:   

Date of Birth (MM/DD/YYYY) :      Social Security #(XXX-XX-XXXX):

MARRIED? Please Enter the Following Information:

Marriage Date (MM/DD/YYYY) :      Separation Date (MM/DD/YYYY) :     

Divorce Date (MM/DD/YYYY) :

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Information about Your Spouse:

First Name:                  Last Name:   

Date of Birth (MM/DD/YYYY):      Social Security #(XXX-XX-XXXX)):

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2) YOUR CONTACT INFORMATION

          Primary Phone#:           Emergency#:                            

Email Address(e.g., pete@petelorins.com):

                 Address:      Street:    

         City:        

                           State:        Zip Code:

                 HOW LONG?       

Best Phone Contact Time:

How Did You Hear About Us?  News Paper Other Word of Mouth Flyer Recruiter Referral Consumer Referral The Internet Direct Mail Referred by a Friend Referred by an Acquaintance

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3) BANKRUPTCY SPECIFIC INFORMATION

Please gather the following so that they'll be ready

to complete the forms for your Bankruptcy Petition:

:: Most Recent Six Months of Pay stubs (for each person filing) ::

:: Most Recent 3 Months of all Bank Statements ::

:: Income Tax Returns For the Past Three Years prior to this current year (Not W-2) ::

:: Most Recent Statements for ALL IRA Accounts; 401-K Accounts;

And other Retirement Accounts/Programs ::

:: Income Tax Returns For the Past Three Years prior to this current year (Not W-2) ::

:: Copy of Most Recent Mortgage Statement ::

:: Copy of Registration For All Motor Vehicles You Own ::

Other Name That You used in the Past 6 Years:

Other Name That Your Spouse used in the Past 6 Years:

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Engaged in a Business? Enter The Business Name Here!

             HOW LONG?       

           Type of Business

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CREDITORS

Secured Debts:

Name of Creditor#1:

Address (: Include City & Zip Code)

                                          Account#:    What is Being Financed?

                                          Type of Debt: Mortgage   | Auto Loan   | Other =>

                                          Amount Owed: $    |   Monthly Payment Amount: $

Purchase Date (MM/DD/YYYY) =>

I'm Keeping This Item   |     I'm Returning This Item

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Name of Creditor#2:

Address (Include City & Zip Code):

                                          Account#:    What is Being Financed?

                                          Type of Debt: Mortgage   | Auto Loan   | Other =>

                                          Amount Owed: $    |   Monthly Payment Amount: $

Purchase Date (MM/DD/YYYY) =>

I'm Keeping This Item   |     I'm Returning This Item

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Name of Creditor#3:

Address (Include City & Zip Code):

                                          Account#:    What is Being Financed?

                                          Type of Debt: Mortgage   | Auto Loan   | Other =>

                                          Amount Owed: $    |   Monthly Payment Amount: $

Purchase Date (MM/DD/YYYY) =>

I'm Keeping This Item   |     I'm Returning This Item

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Name of Creditor#4:

Address (Include City & Zip Code):

                                          Account#:    What is Being Financed?

                                          Type of Debt: Mortgage   | Auto Loan   | Other =>

                                          Amount Owed: $    |   Monthly Payment Amount: $

Purchase Date (MM/DD/YYYY) =>

I'm Keeping This Item   |     I'm Returning This Item

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TAX OBLIGATIONS:

Name of Agency#1:

Agency's Complete Address:

                                                  Amount Owed:$    Reason:

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Name of Agency#2:

Agency's Complete Address:

                                                   Amount Owed:$    Reason:

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STUDENT LOANS:

Name of Agency#1:

Agency's Complete Address:

                                                  Amount Owed:      Reason:

                                                  Account#:     Date Incurred:

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Name of Agency#2:

Agency's Complete Address:

                                                  Amount Owed:      Reason:

                                                  Account#:     Date Incurred:

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Unsecured Debts:

NAME#1:

ADDRESS:

                                                  Amount Owed:       Year Opened:

                                                  Account#:     Balance:

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NAME#2:

ADDRESS:

                                                  Amount Owed:       Year Opened:

                                                  Account#:     Balance:

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NAME#3:

ADDRESS:

                                                  Amount Owed:       Year Opened:

                                                  Account#:     Balance:

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NAME#4:

ADDRESS:

                                                  Amount Owed:       Year Opened:

                                                  Account#:     Balance:

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NAME#5:

ADDRESS:

                                                  Amount Owed:       Year Opened:

                                                  Account#:     Balance:

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NAME#6:

ADDRESS:

                                                  Amount Owed:       Year Opened:

                                                  Account#:     Balance:

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NAME#7:

ADDRESS:

                                                  Amount Owed:       Year Opened:

                                                  Account#:     Balance:

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NAME#8:

ADDRESS:

                                                  Amount Owed:       Year Opened:

                                                  Account#:     Balance:

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NAME#9:

ADDRESS:

                                                  Amount Owed:       Year Opened:

                                                  Account#:     Balance:

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NAME#10:

ADDRESS:

                                                  Amount Owed:       Year Opened:

                                                  Account#:     Balance:

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ASSETS

NON-DISCLOSURE OF YOUR ASSETS MAY RESULT

IN DENIAL OF YOUR PETITION:

Personal Property:

How Much Cash do you have with you?  $

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LIST ALL CURRENT BANK ACCOUNTS

BANK NAME#1:

ADDRESS:

                                                  Account#:     Balance:

PERSONS AUTHORIZED TO USE THIS ACCOUNT:

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BANK NAME#2:

ADDRESS:

                                                  Account#:     Balance:

PERSONS AUTHORIZED TO USE THIS ACCOUNT:

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BANK NAME#3:

ADDRESS:

                                                  Account#:     Balance:

PERSONS AUTHORIZED TO USE THIS ACCOUNT:

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LIST ALL OUTSTANDING SECURITY DEPOSITS

LANDLORD:        AMOUNT: $

UTILITY:        AMOUNT: $

OTHER1:        AMOUNT: $

OTHER2:        AMOUNT: $

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LIST AUTOMOBILES YOU OWE NOTHING ON

YEAR & MAKE:        VALUE: $

YEAR & MAKE:        VALUE: $

YEAR & MAKE:        VALUE: $

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LIST THE VALUE FOR THE FOLLOWING ITEMS --  IF YOU OWN THEM:

CLOTHING: $    

JEWELRY: $    

BOOKS

Name of the Book1:      

Value of the Book: $    

---

Name of the Book2:      

Value of the Book: $    

---

Name of the Book3:      

Value of the Book: $    

---

Name of the Book4:      

Value of the Book: $    

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OBJECTS OF ART

OBJECT OF ART1:      

Value of the Object of Art: $    

---

OBJECT OF ART2:      

Value of the Object of Art: $    

---

OBJECT OF ART3:      

Value of the Object of Art: $    

---

OBJECT OF ART4:      

Value of the Object of Art: $    

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SAVINGS BONDS, STOCKS & CERTIFICATES OF DEPOSIT

SAVINGS BONDS:      

Value of Bonds: $    

STOCKS:      

Value of Stocks: $    

CDs:      

Value of CDs: $    

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LIFE INSURANCE POLICIES AND/OR ANNUITIES

NAME OF COMPANY1:      

VALUE: $    

POLICY#:      

Address:      

NAME OF COMPANY2:      

VALUE: $    

POLICY#:      

Address:      

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EMPLOYER-PROVIDED SAVINGS, RETIREMENT, AND PROFIT SHARING PLANS

PLAN DESCRIPTION1:      

VALUE: $    

PLAN DESCRIPTION2:      

VALUE: $    

PLAN DESCRIPTION3:      

VALUE: $    

PLAN DESCRIPTION4:      

VALUE: $    

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HOUSEHOLD GOODS

FURNITURE

LIVING ROOM SET:      VALUE: $    

DINING ROOM SET:      VALUE: $    

KITCHEN SET:               VALUE: $    

BEDROOM SET#1:      VALUE: $    

BEDROOM SET#2:      VALUE: $    

BEDROOM SET#3:      VALUE: $   

BEDROOM SET#4:      VALUE: $    

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APPLIANCES

STEREO:      VALUE: $      Monthly Payments

TV:                 VALUE: $      Monthly Payments

DVD:             VALUE: $      Monthly Payments

VCR:             VALUE: $      Monthly Payments

Answering Machine:        VALUE: $      Monthly Payments

Washer & Dryer:      VALUE: $      Monthly Payments

Refrigerator:              VALUE: $      Monthly Payments

STOVE:                       VALUE: $      Monthly Payments

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BOATS YOU OWN THAT ARE PAID FOR

DESCRIPTION1:      VALUE: $  

DESCRIPTION2:      VALUE: $  

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MACHINERY OR TOOLS YOU OWN THAT ARE PAID FOR

DESCRIPTION:      VALUE: $  

DESCRIPTION:      VALUE: $  

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ANY LAWSUITS THAT YOU MAY BE ABLE TO BRING AGAINST ANOTHER PERSON

PERSON'S NAME:    

PERSON'S ADDRESS:    

REASON:   

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ANY DEBTS THAT ARE OWED TO YOU BY ANOTHER PERSON

PERSON'S NAME:    

PERSON'S ADDRESS:    

DEBT AMOUNT: $    

REASON:   

---

PERSON'S NAME:    

PERSON'S ADDRESS:    

DEBT AMOUNT: $    

REASON:   

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LIST ANY OTHER PERSONAL PROPERTY THAT ARE NOT LISTED HERE

DESCRIPTION1:      VALUE: $    

DESCRIPTION2:      VALUE: $    

DESCRIPTION3:      VALUE: $    

DESCRIPTION4:      VALUE: $    

DESCRIPTION5:      VALUE: $    

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Real Property:

LIST ANY REAL ESTATE OWNED BY YOU OR IN WHICH YOU HAVE ANY INTEREST

DESCRIPTION:      

FAIR MARKET VALUE: $  

DESCRIPTION:      

FAIR MARKET VALUE: $  

DESCRIPTION:      

FAIR MARKET VALUE: $  

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LEASES:

LIST ANY LEASES TO WHICH YOU ARE, CURRENTLY, A  PARTY

OTHER PARTY1:      

ADDRESS:         

DESCRIPTION:      

---

OTHER PARTY2:      

ADDRESS:         

DESCRIPTION:      

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Income & Expenditures

How often are you paid?   Weekly   |    Bi-Weekly   |  Twice-a-Month  |   Once-a-Month

GROSS PAY: $          NET "TAKE HOME" PAY: $

----

How often is your spouse paid?   Weekly   |    Bi-Weekly   |  Twice-a-Month  |   Once-a-Month

SPOUSE'S GROSS PAY: $         SPOUSE'S NET "TAKE HOME" PAY: $

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PLEASE KEEP A COPY OF YOUR MOST RECENT PAY STUB FOR VERIFICATION

LIST ANY OTHER SOURCES OF INCOME

BUSINESS/PROFESSION:           AMOUNT: $    

RENTAL PROPERTY:                     AMOUNT: $    

INTEREST/ DIVIDENDS:               AMOUNT: $    

SOCIAL SECURITY:                         AMOUNT: $    

GOVERNMENT ASSISTANCE:      AMOUNT: $    

PENSION / RETIREMENT:               AMOUNT: $    

ALIMONY:                                             AMOUNT: $    

OTHER:                                                 AMOUNT: $    

ARE YOU LIKELY TO SEE CHANGES IN THE ABOVE FIGURES IN THE NEAR FUTURE?

YES   |    NO

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LIST ANY DEPENDENTS THAT YOU RECEIVE MONEY FOR

NAME1:   AGE:     RELATIONSHIP:      AMOUNT: $

NAME2:   AGE:     RELATIONSHIP:      AMOUNT: $

NAME3:   AGE:     RELATIONSHIP:      AMOUNT: $

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LIST ANY DEPENDENTS YOU SUPPORT THAT RESIDES WITH YOU

NAME1:   AGE:     RELATIONSHIP:      AMOUNT: $

NAME2:   AGE:     RELATIONSHIP:      AMOUNT: $

NAME3:   AGE:     RELATIONSHIP:      AMOUNT: $

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MONTHLY EXPENSES

RENT / HOME MORTGAGE: $    

WATER, SEWER & GARBAGE: $    

ELECTRICITY: $    

TELEPHONE (Including Cell): $    

CABLE, SATELLITE, OR INTERNET: $    

OTHER UTILITIES:   AMOUNT: $    

HOME MAINTENANCE: $             FOOD: $    

CLOTHING: $         LAUNDRY/ DRY CLEANING: $    

HEALTH: $    

TRANSPORTATION (Gas, Toll, Parking, and Repairs): $    

RECREATION: $      CHARITABLE CONTRIBUTIONS: $    

HOMEOWNER'S INSURANCE: $       LIFE INSURANCE: $    

HEALTH INSURANCE: $     AUTO INSURANCE: $    

OTHER INSURANCE (describe)   VALUE: $    

TAXES: $         AUTO INSTALLMENT PAYMENT: $    

OTHER INSTALLMENTS (describe)   VALUE: $    

ALIMONY, MAINTENANCE & SUPPORT TO OTHERS: $    

PAYMENT FOR SUPPORT OF DEPENDENTS NOT LIVING AT HOME: $    

BUSINESS OPERATION EXPENSES: $    

HOME OWNER'S ASSOCIATION DUES: $        SECURITY: $    

BANK SERVICE CHARGES & POSTAGE: $    

CHILD CARE: $      HAIRCUTS, COSMETICS, Etc. : $    

PET SUPPLIES: $       VETERINARY EXPENSES: $    

OTHER MONTHLY EXPENSES: $    

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CHILD SUPPORT OR MAINTENANCE PAYMENTS PAYABLE BY YOU OR

YOUR SPOUSETO SOMEONE ELSE

NAME1:   AGE:     RELATIONSHIP:      AMOUNT: $

NAME2:   AGE:     RELATIONSHIP:      AMOUNT: $

NAME3:   AGE:     RELATIONSHIP:      AMOUNT: $

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ALIMONY PAYMENTS PAYABLE BY YOU OR YOUR SPOUSE

NAME1:   AGE:     RELATIONSHIP:      AMOUNT: $

NAME2:   AGE:     RELATIONSHIP:      AMOUNT: $

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LIST ALL DEPENDENTS THAT YOU SUPPORT BUT DOES NOT RESIDE WITH YOU

NAME:   AGE:     RELATIONSHIP:      AMOUNT: $

NAME:   AGE:     RELATIONSHIP:      AMOUNT: $

NAME:   AGE:     RELATIONSHIP:      AMOUNT: $

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FINANCIAL AFFAIRS

YOUR EMPLOYMENT INFORMATION

State your current employer and address:

How long have you been working there?:

POSITION/ FUNCTION:

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YOUR SPOUSE'S EMPLOYMENT INFORMATION

State your spouse's current employer and address:

How long have you been working there?:

POSITION/ FUNCTION:

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HAVE YOU EVER FILED FOR BANKRUPTCY BEFORE?    

YES    |     NO

IF YES, PLEASE ANSWER THE FOLLOWING QUESTIONS:

When did you file? ==>

Where did you file? ==>

Bankruptcy Type ==>

Result of the filing ==>

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YOUR GROSS EMPLOYMENT INCOME FOR THE PAST THREE (3) YEARS:

PREVIOUS YEAR (e.g., 2008):       AMOUNT: $

YEAR PRIOR TO IT (e.g., 2007):    AMOUNT: $

NEXT PRIOR YEAR (e.g., 2006):    AMOUNT: $

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YOUR SPOUSE'S GROSS EMPLOYMENT INCOME FOR THE PAST THREE (3) YEARS:

PREVIOUS YEAR (e.g., 2008):       AMOUNT: $

YEAR PRIOR TO IT (e.g., 2007):    AMOUNT: $

NEXT PRIOR YEAR (e.g., 2006):    AMOUNT: $

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YOUR GROSS INCOME FROM ANY OTHER SOURCE FOR THE PAST THREE (3) YEARS:

PREVIOUS YEAR (e.g., 2008):       AMOUNT: $

YEAR PRIOR TO IT (e.g., 2007):    AMOUNT: $

NEXT PRIOR YEAR (e.g., 2006):    AMOUNT: $

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YOUR SPOUSE'S GROSS INCOME FROM ANY OTHER SOURCE FOR THE PAST THREE (3) YEARS:

PREVIOUS YEAR (e.g., 2008):       AMOUNT: $

YEAR PRIOR TO IT (e.g., 2007):    AMOUNT: $

NEXT PRIOR YEAR (e.g., 2006):    AMOUNT: $

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CREDITORS TO WHICH YOU MADE PAYMENTS OTHER THAN REGULAR MONTHLY PAYMENTS:

NAME1:    AMOUNT: $    DATE:

NAME2:    AMOUNT: $    DATE:

NAME3:    AMOUNT: $    DATE:

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PAYMENTS TO :RELATIVES OR BUSINESS PARTNERS MADE IN THE PAST YEAR

NAME1:    AMOUNT: $    DATE:

NAME2:    AMOUNT: $    DATE:

NAME3:    AMOUNT: $    DATE:

NAME4:    AMOUNT: $    DATE:

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ANY LAWSUITS IN WHICH YOU WERE/ARE A PARTY WITHIN THE LAST YEAR:

OTHER PARTY:     TYPE OF SUIT:

COURT:     STATUS:

---

OTHER PARTY:     TYPE OF SUIT:

COURT:     STATUS:

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LIST ANY PROPERTY :ATTACHED, GARNISHED, OR SEIZED WITHIN THE PAST YEAR

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 PROPERTY RETURNED, REPOSSESSIONS, OR FORECLOSURES WITHIN THE PAST YEAR:

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CHARITABLE CONTRIBUTIONS OF $100 OR MORE MADE IN THE PAST YEAR:

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LOSSES INCURRED FROM THEFT, GAMBLING & FIRE, OR OTHERWISE WITHIN THE PAST YEAR:

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NAMES OF ALL LAWYERS CONSULTED WITHIN THE PAST YEAR REGARDING BANKRUPTCY:

NAME1:    DATE:      AMOUNT: $   

NAME2:    DATE:      AMOUNT: $   

NAME3:    DATE:      AMOUNT: $   

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PROPERTIES SOLD OR GIVEN AWAY WITHIN THE PAST YEAR:

DESCRIPTION1:    DATE:      AMOUNT: $   

DESCRIPTION2:    DATE:      AMOUNT: $   

DESCRIPTION3:    DATE:      AMOUNT: $   

DESCRIPTION4:    DATE:      AMOUNT: $   

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BANK ACCOUNTS OR INSTRUMENTS CLOSED, CASHED, OR TRANSFERRED WITHIN THE PAST YEAR:

DESCRIPTION1:    DATE:     

DESCRIPTION2:    DATE:     

DESCRIPTION3:    DATE:     

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ALL SAFE DEPOSIT BOXES KEPT IN THE PAST YEAR:

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ALL PROPERTY YOU HAVE BELONGING TO ANOTHER PERSON:

DESCRIPTION1:    VALUE: $   

NAME & ADDRESS ==>

---

DESCRIPTION2:    VALUE: $   

NAME & ADDRESS ==>

---

DESCRIPTION3:    VALUE: $   

NAME & ADDRESS ==>

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LIST ALL PRIOR ADDRESSES FOR THE PAST TWO (2) YEARS:

From :    To:  

Address1:

From :    To:  

Address2:

From :    To:  

Address3:

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BOOKKEEPERS OR ACCOUNTANTS THAT KEPT/SUPERVISED YOUR BOOKS DURING PAST SIX (6) YEARS:

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ANY BUSINESSES YOU HAVE OPERATED IN THE PAST YEAR:

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YOU SIGNATURE (Enter Your Social Security#) ==>             DATE:

SPOUSE'S SIGNATURE (His/Her Social Security#) ==>     DATE:

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4) Are you Interested in any Of Our Other Services ( OTHER OPTIONS)

                                                           DIVORCE            CHILD SUPPORT       CUSTODY

                                                           ALIMONY                 BANKRUPTCY                FORECLOSURE

                                                           IMMIGRATION         TAX                                  INCORPORATION      

                                                           COPYRIGHT             PATENT                           TRADEMARK  

                                                           FRANCHISE             DOCUMENT REVIEW      RECORD EXPUNGEMENT

                                                           GRANT WRITING    INTERNET/WEB               RESUME FORMATTING

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                                                                         FREE LAWYER REFERRAL                   NOTARY SERVICES

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