Bankruptcy, Debt & Housing – Interview Form

Fill the form below and press "SUBMIT" OR click here to print out the form, fill it out and send back to us.
Our Consultations are Free. Tel: (562) 303-1222 * Fax: (562) 303-1223

GENERAL INFORMATION

Date:

How did you hear about us:

Name:

Spouse's Name:

Address:

City:

Zip:

Phone:

Phone #2:

Email:

DO YOU HAVE A VALID SS#:

YES:

NO:

DO YOUR SPOUSE HAVE A VALID SS#:

YES:

NO:

HAVE YOU FILED BK BEFORE:

YES:

NO:

IF YES: CASE #

DATE FILED:

INCOME

Occupation:

Monthly Net:

Spouse's Occupation:

Monthly Net:

Monthly Net from all other sources (rent, disability, EDD, support, family):

UNSECURED DEBT
ARE YOU BEING HARASSED BY ANY CREDITORS? yes no

Credit Cards:

Personal Loans:

Lawsuits:

Medical Bills:

Federal Taxes:

State Taxes:

Child Support:

Monthly Payment:

Spousal Support:

Monthly Payment:

SECURED DEBT ("arrears" = missed payments)

CAR #1: Year, Make, Model:

Mileage:

Balance:

Arrears:

CAR #2: Year, Make, Model:

Mileage:

Balance:

Arrears:

CAR #3: Year, Make, Model:

Mileage:

Balance:

Arrears:

HOUSE #1: Address/City/State:

Purchase Date:

1st MORTGAGE > Monthly Payment:

Balance:

Arrears:

2nd MORTGAGE > Monthly Payment:

Balance:

Arrears:

HOUSE #2: Address/City/State:

Purchase Date:

1st MORTGAGE > Monthly Payment:

Balance:

Arrears:

2nd MORTGAGE > Monthly Payment:

Balance:

Arrears:

MISCELLANEOUS

KIDS LIVING WITH YOU:

#under 18:

#over 18:

TRANSFERS: Have you sold or gifted any house, land or money in the last year?

Yes:

No:

What:

Who:

When:

How much:

OTHER: (ex. what's your next goal?)

We are a debt-relief agency, we help people file for bankruptcy relief under the Bankruptcy Code.

The information you obtain at this site is not, nor is it intended to be, legal advice. You should consult an attorney for advice regarding your individual situation.
We invite you to contact us and welcome your calls, letters and electronic mail. Contacting us does not create an attorney-client relationship.
Please do not send any confidential information to us until such time as an attorney-client relationship has been established.

Gonzales & Jackson, LLP

PO Box 14566
Long Beach, CA 90803
Tel: (562) 303-1222
Fax: (562) 303-1223
www.gonzalesjackson.com

Bankruptcy, Debt & Housing – Interview Form

GENERAL INFORMATION

INCOME

UNSECURED DEBT ARE YOU BEING HARASSED BY ANY CREDITORS? yes no

SECURED DEBT ("arrears" = missed payments)

MISCELLANEOUS

UNSECURED DEBT
ARE YOU BEING HARASSED BY ANY CREDITORS? yes no