NameBankruptcy Case Evaluation Form First Name * Last Name Email Address * Phone Number * Spouse First Name Spouse Last Name Street Address City State Zip Code Number of Dependents 0 1 2 3 4 5 6 7 8 What type of bills do you have? Credit Cards Medical Bills Judgment Student Loans Mortgage Auto Loan Tax Debts Government Fines Personal Loans Number of bills Approximate Income 1 Approximate Debt 1 Approximate Home Value 1 Approximate Home Mortgage Balance 1 Past Due Balance on Mortgage Yes No Approximate Auto(s) Value 1 Approximate Auto(s) Loan Balance 1 Past Due Balance on Auto Loan Yes No Previous Bankruptcy Filing Yes No If Yes, when and what Chapter? Pending Legal Action Foreclosure Repossession Lawsuit Garnishment
