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Questionnaire

It Is Our Sincere Desire to Help You

Your answers on this form give us important information that will allow us to better help you. Please complete the entire form. If you don't know exact figures, please provide your best answer. Your answers are confidential. Please answer honestly.

First Name:
Last Name:
Address:
City:
ZIP:
Contact Phone Number:
E-Mail Address:
Date of Birth:
Occupation:
Employer:
Length of Employment:
Marital Status:
Dependents living at home:
No Yes
How long have you lived in Texas?
Have you EVER filed bankruptcy?
No Yes

Homes/Land/Real Estate of any kind

List ALL real estate you own, even if it is paid off.

Property #1 Address:
Mortgage Company (if any):
Monthly Payment, $:
Payoff/Balance Due, $:
Amount Behind, $:
Value, $:
Second Mortgage (if any):
Monthly Payment, $:
Payoff/Balance Due, $:
Amount Behind, $:
Real Estate Taxes Due?
No Yes
Property #2 Address:
Mortgage Company (if any):
Monthly Payment, $:
Payoff/Balance Due, $:
Amount Behind, $:
Value, $:
Second Mortgage (if any):
Monthly Payment, $:
Payoff/Balance Due, $:
Amount Behind, $:
Real Estate Taxes Due?
No Yes
Property #3 Address:
Mortgage Company (if any):
Monthly Payment, $:
Payoff/Balance Due, $:
Amount Behind, $:
Value, $:
Second Mortgage (if any):
Monthly Payment, $:
Payoff/Balance Due, $:
Amount Behind, $:
Real Estate Taxes Due?
No Yes

Vehicles

List ALL vehicles you own, even if it is paid off.

Year / Make / Model:
Creditor (if any):
Balance Due, $:
Monthly Payment, $:
Value, $:
Amount Behind, $:
Year / Make / Model:
Creditor (if any):
Balance Due, $:
Monthly Payment, $:
Value, $:
Amount Behind, $:
Year / Make / Model:
Creditor (if any):
Balance Due, $:
Monthly Payment, $:
Value, $:
Amount Behind, $:

Other Secured Debts

Furniture/appliances, electronics, jewelry, RVs, motorcycles, boats, trailers, etc.

Creditor:
Collateral:
Balance Due, $:
Monthly Payment, $:
Value, $:
Creditor:
Collateral:
Balance Due, $:
Monthly Payment, $:
Value, $:
Creditor:
Collateral:
Balance Due, $:
Monthly Payment, $:
Value, $:

IRS Debt

IRS Debt Years:
Approx. Total Amount:
Have you filed all of your income tax returns for this year and previous years?
Yes No

Unsecured Debts

What is the approximate total of all other debts you have? Include all other debts, even if you dispute the debt or it is "written off" or you want to continue paying it. Examples are: credit cards, payday loans, medical bills, signature loans, bad checks, etc.

Total Unsecured Debt, $:
Cash
Checking Accounts (combined)
Business Checking (combined)
Savings (combined)
Money Owed to you
Stocks
Receivables
Tax Refunds
Business Ownership (value of shares)
Inventory
Tools of Trade
Antiques/Jewelry
Valuable Collections
Personal Injury Claim
If you own your home, have you lived there less than 40 months?
No Yes
Do you belong to a credit union?
No Yes
Do you have any insufficient funds (NSF) checks outstanding?
No Yes
Are any being collected by the district attorney?
No Yes
Are you behind on child or spousal support?
No Yes
Do you have any judgments against you?
No Yes
Do you have any lawsuits pending?
No Yes
Have you received any cash advances, used balance transfers or credit card "convenience" checks in the last 12 months?
No Yes
Is your employer or a creditor taking any deductions out of your paycheck or bank account for loans, car payments, payday loans etc.?
No Yes
Do you have any retirement (401K) loans?
No Yes
Do you owe anything to family, friends, or business partners?
No Yes
Do you have a debt that is joint (cosigned) with someone else?
No Yes
Do you pay a debt that is in someone else's name?
No Yes
Have you sold or given away anything worth over $1,000.00 to anyone in the past 24 months?
No Yes
How much is your gross monthly income:
Pay Period:
How much is your take home pay?
How much is your spouses' gross monthly income:
Spouse's Pay Period:
How much is your Spouse's take home pay?
Please report your spouse's income even if you do not think he/she will be filling with you.
Other monthly household income of any type (second job, child support, food stamps, rental income, Social Security, etc.)?

Please estimate if you do not know exact amounts.

Home mortgage payment or rent
Are real estate taxes included?
Yes No
Is property insurance included?
Yes No
Lot rental, land payment or homeowner's association
Electricity and heating fuel (natural gas/propane)
Water and Sewer
Telephone (regular land line)
Other (cable or satellite)
Home maintenance
Food (include groceries, toiletries, cleaning supplies)
Clothing
Laundry & Dry Cleaning
Medical & Dental expenses (not payroll deducted)
Transportation (gas/repairs/maintenance)
Recreation
Charitable contributions
Insurance (not deducted from wages or included in home mortgage payment)
Homeowner's or renter's
Life
Health
Auto
Other
Installment payments:
Auto
Other
Other
Taxes (not deducted from wages or included in home mortgage payment)
Alimony, maintenance and support paid to others
Payments for support of additional dependents not living at your home
Other (cell phone)
Other (interet)
Other
How did you hear about us:
I have read and understand the disclaimer.
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