Bankruptcy Questionnaire

Contact Information

First Name:

Last Name:

Phone Number:

Email:

What You Owe: Please State Amount

IRS Debt:

Credit Card Debt:

Medical Debt:

Repossession:

Other:

Please check all that apply:

Are you obligated to pay child support pursuant to a Domestic Support Obligation agreement or order?

You: Yes No

Spouse: Yes No

Have you filed bankruptcy before?

You: Yes No

Spouse: Yes No

Are you suing anyone in any Court on any matter?

You: Yes No

Spouse: Yes No

Have you transferred, sold or gifted any property to a third party in the past two years?

You: Yes No

Spouse: Yes No

Have you repaid any loans to individuals within the past year?

You: Yes No

Spouse: Yes No

Have you settled any claims wherein you received money in the last year?

You: Yes No

Spouse: Yes No

Have you lived in Florida continuously for the last two (2) years?

You: Yes No

Spouse: Yes No

Does anyone owe you money for any reason?

You: Yes No

Spouse: Yes No

Are you a beneficiary of any will, trust or estate?

You: Yes No

Spouse: Yes No

Have you made any payments totaling more than $600 to any unsecured creditor during the last 90 days?

You: Yes No

Spouse: Yes No

Have you used any credit cards in the last 90 days?

You: Yes No

Spouse: Yes No

Things You Own

Vehicle 1

Vehicle Type:

Approximate Value:

Amount Owed:

Vehicle 2

Vehicle Type:

Approximate Value:

Amount Owed:

Vehicle 3

Vehicle Type:

Approximate Value:

Amount Owed:

Property 1

Real Property Type:

Approximate Value:

Amount Owed:

Property 2

Real Property Type:

Approximate Value:

Amount Owed:

Property 3

Real Property Type:

Approximate Value:

Amount Owed:

Approximate balance of all bank accounts or other financial accounts:

Note: Do not include IRA or other retirement accounts.

Balance:

Additional Info

Provide additional information you believe may be relevant:

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Contact Information

What You Owe: Please State Amount

Please check all that apply:

Things You Own

Vehicle 1

Vehicle 2

Vehicle 3

Property 1

Property 2

Property 3

Approximate balance of all bank accounts or other financial accounts:

Additional Info