This short form is totally optional. You can either call us with this information or you can fill this out and forward it to us and we will know quickly if you appear to be a good candidate for bankruptcy relief. If so, we will be happy to schedule your appointment in our Rock Island Office.
Jim does respond to these forms on evenings/weekends as time allows, so feel free to send it to us at any time.
This form is for Iowa and Illinois residents only.
2. Real Estate
(If you do not own real estate, go to section 3)
If you own your home, please enter the following information.
Year Purchased
Current REALISTIC market value estimate
$
Total owed on your primary mortgage:
$
Total owed on your 2nd mortgage:
$
Total owed on your 3rd mortgage:
$
Do you still have substantial credit card debt that you had before you bought your home?
NoYes
Do you intend to keep or give back your home?
KeepGive Back
Is your home in foreclosure?
NoYes
Do you own any other real estate, time share, etc.?
NoYes
Property Type
Property Value
Owed On Property
Year Purchased
$
$
$
$
$
$
3. Vehicles
(If you do not own a vehicle, go to section 4)
Year, Make, & Model
Fair Market Value
Amount Owed
Keep or Give Back
$
$
KeepGive Back
$
$
KeepGive Back
$
$
KeepGive Back
4. Debts
List the estimated amounts for each of the following debt types (do not include debts for home & cars listed above):
Credit Cards
$
Medical
$
Bank Loans
$
Debts to Family Members
$
Other Debts
$
Have you charged, transferred balances, or taken cash advances exceeding $500 in the past 60 days?
NoYes
If yes, how much?
$
to whom?
5. Income
Enter your total monthly take home income. Include employment, unemployment, social security, pension, child support, etc.
$
6. Business
(If you do not own a vehicle, go to section 7)
Is the business incorporated?
NoYes
Value of Business Equipment
$
Amount OWED on Business Equipment
$
Value of Business Inventory
$
Value of Accounts Receivable
$
7. Retirement accounts and Investments
Enter the approximate balance and type of any EMPLOYER sponsored retirement or other investments including annuities (401K, IPERS, Thrift, etc.)
Investment Type
Investment Value
$
$
$
$
Enter the approximate balance and type of any NON-employer sponsored retirement or other investments including annuities
$
$
$
$
8. Other Questions
Have you made payments over $600 to any ONE UNsecured creditor in the past 90 days?
NoYes
How Much?
$
Have you given away valuable property within the last year?
NoYes
If yes, describe:
Do you have any garnishments or repossessions in progress?
NoYes
If yes, describe:
When will you be garnished next?
/ / xx/xx/xxxx
Do you normally receive more than $1,000 individually or $2,000 jointly in tax refunds each year?
NoYes
If yes, do you get Earned Income Credit?
NoYes
Do you have a camper, motorcycle, boat, snowmobile, trailer, jet ski, expensive mower, etc.?
NoYes
If yes, enter the current market value:
$
loan amount:
$
List any other significant assets including cash.
Asset
Value
$
$
$
$
Do you have any pending lawsuits, personal injury claims, workers compensation claims, etc?
NoYes
If yes, explain:
Enter the approximate amount of any gambling losses in the last year.
$
Has anyone ever sued you and obtained a judgment that is not yet paid off?
NoYes
If yes, when?
Where?
Amount $
Have you repaid a relative or business partner in the past year?
NoYes
If yes, when?
Amount $
Have you made any gifts of unusual sizes ($200 or more to a family member, or $100 or more to a charity) in the past year?
NoYes
If yes, when?
Who?
Amount $
9. Our First Meeting
If you feel you are ready to get started on your case (assuming the above information is satisfactory), please indicate any dates or times that are convenient for you to meet:
Do you have any specific questions for Jim?
Thank you for providing this information - when you click "SEND NOW" I will review the information and contact you to schedule an appointment. I look forward to meeting with you very soon!
