Free Bankruptcy Evaluation Form

What are your financial problems? (check all that apply) What are your financial problems? (check all that apply) Credit Card Problems Medical Bill Problems House Payments Past Due Other

What caused your financial problems? (check all that apply) What caused your financial problems? (check all that apply) Job Loss Health Problems Divorce Other

What debt collection problems are you experiencing? (check all that apply) What debt collection problems are you experiencing? (check all that apply) Telephone calls at home or work Garnishment of your wages/bank account Lawsuits, actual or threats Other

What is your average monthly take home pay? What is your average monthly take home pay?Under $1,000Between $1,000 and $2,000Between $2,000 and $3,000Between $3,000 and $4,000Between $4,000 and $5,000Between $5,000 and $6,000Between $6,000 and $7,000Over $7,000 per month

Your marital status (choose one) Your marital status (choose one) Single Married Divorced / Separated

Does anyone else contribute to your household income? (choose one) Does anyone else contribute to your household income? (choose one) Yes No

How ready are you to fix your financial problems? How ready are you to fix your financial problems? Not ready yet - still thinking about it. I'm ready to get started and want to know my options. I need help NOW!

What's your biggest fear about your finances? (check all that apply) What's your biggest fear about your finances? (check all that apply) My expenses take all my income, I'll never get out of debt My expenses exceed my income, I'm drowning in debt My expenses far exceed my income. I need help now!

What options have you considered? (check all that apply) What options have you considered? (check all that apply) None yet Credit Counseling Debt Management Plan Debt Consolidation Loan Using my retirement plan Borrowing from family or friends Selling property you own Chapter 7 Chapter 13 Other

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