Please enable JavaScript in your browser to complete this form. – Step 1 of 2Please fill in ALL blanks below or write N/A if the question is not applicable.Individual Filer/Husband:I am filing as: SingleMarriedWidowedSeperatedDivorced or Divorce PendingLiving with SomeoneName *FirstLastMiddle Name *If you do not have a middle name say noneList all current or previous names including Former, Maiden, AKA, Alias, DBAHusband/Individual Filer AddressAddress Line 1Address Line 2CityAlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingStateZip CodeCounty of ResidenceLength of Time at current addressDate of BirthLast 4 Digits of Social Security NumberCell Phone NumberHome Phone NumberWork Phone NumberEmail *Emergency Contact NameEmergency Contract Relationship to YouEmergency Contact Phone NumberWife's Information (Fill out even if Wife is not filing)I understand that I must provide non filing spouse income information (also applies to live-in). Debts of non-filer are not discharged.Is your spouse going to file bankruptcy with you?YesNoHas your spouse ever filed bankruptcy?YesNoSpouse Name *FirstLastSpouse Middle NameFor Spouse – List all current or previous names including Former, Maiden, AKA, Alias, DBA Do you live at the same address as your husband?YesNoSpouse Address (if different than Husband's address)Address Line 1Address Line 2CityAlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingStateZip CodeFor Spouse – County of Residence Spouse's length of time at current address Spouse's Date of Birth Spouse's Last 4 Digits of Social Security Number Spouse's Cell Phone Number Spouse's Work Phone Number Spouse's Email *Spouse's Emergency Contact Name Emergency Contract Relationship to SpouseFor Spouse – Emergency Contact Phone Number Reason You Came Today/ Reason You Want to File BankruptcyDo you have any of the following below? (If YES, check the item and provide details for each briefly below)Lawsuit or sheriff saleGarnishments on wage accountsPrior bankruptcyRevoked or suspended licenseForeclosure or house months behindAn overpayment of social security or unemployment you have receivedIf you answered YES above, please explainDo you have any creditors suing you?YesNoList all creditors suing youHow much debt do you have? (Exclude any house, car, or student loan debt) *Estimate your debt to the nearest $1000NextREAL ESTATE (Schedule A, Schedule D)Do you own your home or have any other real estate interest?YesNoType of Real Estate – Example: house, timeshare, condo, multi unit, vacant lot, etcAddress of Real EstateUse of Real Estate – Example: Residence, Rental Property, OtherIf other, please explainName(s) on DeedYear PurchasedPurchase PriceAmount Put DownEstimated EquitySquare feet, Number of bedrooms, bathroomsExample: 1400 sq ft, 3 bedrooms, 2 bathEstimated Current Market ValueMust provide a market evaluation of less than 2 years oldDo you own any other property besides what is listed above? If Yes, please explainMORTGAGE INFORMATIONDo you have a mortgage?YesNoName of Mortgage CompanyMortgage Company AddressAccount NumberDate your obtained the mortgageWhose name is on the mortgage?Husband/Individual DebtorWifeBothWhat is the payoff amount of the mortgage?Monthly Mortgage PaymentAre you behind on payments?YesNoIf you are behind on the mortgage, list the months you are behind (Example: July – October)Are taxes and insurance include in your mortgage?YesNoHow much do you pay in taxes per month?How much do you pay for insurance per month?Are your real estate taxes current?YesNoDo you have a second mortgage?YesNoSECOND MORTGAGE INFORMATIONName of Second Mortgage CompanySecond Mortgage Company AddressAccount Number for Second Mortgage CompanyDate Second Mortgage Was ObtainedWhose Name is on the Second Mortgage?Husband/IndividualWifeBothPayoff Amount of Second MortgageMonthly Payment on Second MortgageAre you behind on your second mortgage?YesNoIf you are behind on your second mortgage, what months are you behind? Example: July – OctoberDo you have a third mortgage?YesNoName of Third Mortgage CompanyThird Mortgage Company AddressThird Mortgage Company Account NumberDate you Obtained Third MortgageWhose Name is on the Third MortgageHusband/IndividualWifeBothThird Mortgage Payoff AmountThird Mortgage Monthly PaymentAre you Behind on Payments for the Third Mortgage?YesNoWhat Months are You Behind on the Third Mortgage? (Example: July – October)Do you have a mortgage that has gone to a collection agency?YesNoMortgage Collection Agency NameMortgage Collection Agency AddressAccount Number for Mortgage Collection AgencyDate you Obtained the Mortgage that went to Collection AgencyWhose Name is on the Mortgage that went to the Collection Agency?Husband/IndividualWifeBothPayoff Amount for Mortgage that went to Collection AgencyHave you sued for this mortgage that has gone to the Collection Agency?YesNoIf you have been sued by for the mortgage that has gone to the Collection Agency, provide the lawsuit information belowDo you have any additional real estate?YesNoIf you have additional real estate, please describe it herePreviousNameSubmit
