People's Legal Front

E MAIL ADDRESS:

DEBTOR INFORMATION

Debtor Name Last, First, Middle

Have you had any alias in the last 6 years, if so list:

Your Social Security Number.

Street Address

City

State

Zip Code

Mailing Address if Different from Street Address:

City

State

Zip Code

County of Residence

Area Code and Phone Number:

All Previous Addresses Within Past Six Years, Please include dates at each address:

Marital Status: (Single, Married, Separated, Widowed):

SPOUSE INFORMATION

Spouse Name Last, First, Middle

Have you had any alias in the last 6 years, if so list:

Your Social Security Number.

Street Address

City

State

Zip Code

Mailing Address if Different from Street Address:

City

State

Zip Code

County of Residence

Area Code and Phone Number:

ASSETS

Do you own your own home?
Will you keep it and live in it?
Home Address (Street address, City, State Zip Code) and Description:

Home Value:
*Do you own other property?
*Property Value:
*Property address and description:

Cash On Hand (Value):

Checking Account, Name, Acct # and Value:

Security Deposits (Describe) and Value:

*Collectibles (Describe) and Value:

Wearing Apparel and Value:

Jewelry and furs (Describe) and Value:

HOUSEHOLD GOODS

Audio Equipment (Television, VCR, Stereo (Describe)) and Value:

Washer /Dryer (describe) and Value:

Dining Room (describe contents) and value of each piece:

Living Room (describe contents) and value of each piece:

Bedrooms (describe contents) and value of each piece:

Kitchen,(describe contents) and value of each piece:

Tools (Describe) and Value:

Other Assets (describe) and value:

Office Equipment, furnishings and supplies and Value:

*Sporting equipment including firearms (describe) and Value:

FINANCIAL

*Life Insurance Policy with Cash Value:

*Annuities (Describe) and Value:

*IRA, KEOGH, ERISA or other pension or profit sharing plans (Describe) and Value:

*Stocks (Describe) and Value:

*Alimony , maintenance, support and property settlements to which debtor is or may be entitled to (describe and Value:

VEHICLES

Automobiles, trucks, trailers, and other vehicles (Year, Make, Model) and Value:

Payoff Amount:
Automobiles, trucks, trailers, and other vehicles (Year, Make, Model) and Value:

Payoff Amount:
Automobiles, trucks, trailers, and other vehicles (Year, Make, Model) and Value:

Payoff Amount:
Automobiles, trucks, trailers, and other vehicles (Year, Make, Model) and Value:

Payoff Amount:

DEPENDENTS

Name: Age: Relationship:
Name: Age: Relationship:
Name: Age: Relationship:
Name: Age: Relationship:
Name: Age: Relationship:

EMPLOYER INFORMATION

DEBTOR

Occupation:
Employer Name, Street Address, City, State and Zip Code:

How Long Employed?

SPOUSE

Occupation:
Employer Name, Street Address, City, State and Zip Code:

How Long Employed?

MONTHLY EMPLOYMENT INCOME AND DEDUCTIONS

DEBTOR

Gross Monthly Income:
Monthly Pay Deductions:
Year to Date: *Source:
Last Year: *Source:
Previous Year: *Source:

Spouse

Gross Monthly Income:
Monthly Pay Deductions:
Year to Date: *Source:
Last Year: *Source:
Previous Year: *Source:

EXPENSES

Rent/Mortgage:
Electric/Heating:
Water/Sewer:
Telephone:
Food:
Clothing:
Laundry/Dry Cleaning:
Medical Dental Expense:
Gas/Oil/Repair (Auto):
Auto Insurance:
Auto Payment:
Alimony:
Child Support:
Other Expense: (describe)

CREDITOR INFORMATION:

SECURED CLAIMS (Creditors 1-6)

1.Name:
Account #:
Address:

Date Incurred:
Amount Owed:
Description:
Fair Market Value of Property secured by this debt:
Type of Debt:
*Any Codebtors? (List name and address):

*Under collection or foreclosure? (List Agency name and address):

Will you reaffirm this debt?
2.Name:
Account #:
Address:

Date Incurred:
Amount Owed:
Description:
Fair Market Value of Property secured by this debt:
Type of Debt:
*Any Codebtors? (List name and address):

*Under collection or foreclosure? (List Agency name and address):

Will you reaffirm this debt?
3.Name:
Account #:
Address:

Date Incurred:
Amount Owed:
Description:
Fair Market Value of Property secured by this debt:
Type of Debt:
*Any Codebtors? (List name and address):

*Under collection or foreclosure? (List Agency name and address):

Will you reaffirm this debt?
4.Name:
Account #:
Address:

Date Incurred:
Amount Owed:
Description:
Fair Market Value of Property secured by this debt:
Type of Debt:
*Any Codebtors? (List name and address):

*Under collection or foreclosure? (List Agency name and address):

Will you reaffirm this debt?
5.Name:
Account #:
Address:

Date Incurred:
Amount Owed:
Description:
Fair Market Value of Property secured by this debt:
Type of Debt:
*Any Codebtors? (List name and address):

*Under collection or foreclosure? (List Agency name and address):

Will you reaffirm this debt?
6.Name:
Account #:
Address:

Date Incurred:
Amount Owed:
Description:
Fair Market Value of Property secured by this debt:
Type of Debt:
*Any Codebtors? (List name and address):

*Under collection or foreclosure? (List Agency name and address):

Will you reaffirm this debt?

UNSECURED PRIORITY CLAIMS

List all:
a. Governmental units which you owe taxes, student loans, or other debts.
b. Individuals who have given you money, for the purchase, lease, or rental of property or services for personal, family, or household use that were not delivered or provided.
c. Claims against you by farmers and fishermen.
d. Employee benefit plans that you owe money to within the past 180 days.
e. Employees that you owe money to for wages, salaries, etc. within the past 90 days.
f. Alimony, maintenance, or support.
g. Commitments to maintain the capital of an insured depository institution.

1.Name:
Account #:
Address:

Date Incurred:
Amount Owed:
Description:
Fair Market Value of Property secured by this debt:
Type of Debt:
*Any Codebtors? (List name and address):

*Under collection or foreclosure? (List Agency name and address):

Will you reaffirm this debt?
2.Name:
Account #:
Address:

Date Incurred:
Amount Owed:
Description:
Fair Market Value of Property secured by this debt:
Type of Debt:
*Any Codebtors? (List name and address):

*Under collection or foreclosure? (List Agency name and address):

Will you reaffirm this debt?
3.Name:
Account #:
Address:

Date Incurred:
Amount Owed:
Description:
Fair Market Value of Property secured by this debt:
Type of Debt:
*Any Codebtors? (List name and address):

*Under collection or foreclosure? (List Agency name and address):

Will you reaffirm this debt?
4.Name:
Account #:
Address:

Date Incurred:
Amount Owed:
Description:
Fair Market Value of Property secured by this debt:
Type of Debt:
*Any Codebtors? (List name and address):

*Under collection or foreclosure? (List Agency name and address):

Will you reaffirm this debt?
5.Name:
Account #:
Address:

Date Incurred:
Amount Owed:
Description:
Fair Market Value of Property secured by this debt:
Type of Debt:
*Any Codebtors? (List name and address):

*Under collection or foreclosure? (List Agency name and address):

Will you reaffirm this debt?
6.Name:
Account #:
Address:

Date Incurred:
Amount Owed:
Description:
Fair Market Value of Property secured by this debt:
Type of Debt:
*Any Codebtors? (List name and address):

*Under collection or foreclosure? (List Agency name and address):

Will you reaffirm this debt?
7.Name:
Account #:
Address:

Date Incurred:
Amount Owed:
Description:
Fair Market Value of Property secured by this debt:
Type of Debt:
*Any Codebtors? (List name and address):

*Under collection or foreclosure? (List Agency name and address):

Will you reaffirm this debt?
8.Name:
Account #:
Address:

Date Incurred:
Amount Owed:
Description:
Fair Market Value of Property secured by this debt:
Type of Debt:
*Any Codebtors? (List name and address):

*Under collection or foreclosure? (List Agency name and address):

Will you reaffirm this debt?
9.Name:
Account #:
Address:

Date Incurred:
Amount Owed:
Description:
Fair Market Value of Property secured by this debt:
Type of Debt:
*Any Codebtors? (List name and address):

*Under collection or foreclosure? (List Agency name and address):

Will you reaffirm this debt?
10.Name:
Account #:
Address:

Date Incurred:
Amount Owed:
Description:
Fair Market Value of Property secured by this debt:
Type of Debt:
*Any Codebtors? (List name and address):

*Under collection or foreclosure? (List Agency name and address):

Will you reaffirm this debt?
11.Name:
Account #:
Address:

Date Incurred:
Amount Owed:
Description:
Fair Market Value of Property secured by this debt:
Type of Debt:
*Any Codebtors? (List name and address):

*Under collection or foreclosure? (List Agency name and address):

Will you reaffirm this debt?
12.Name:
Account #:
Address:

Date Incurred:
Amount Owed:
Description:
Fair Market Value of Property secured by this debt:
Type of Debt:
*Any Codebtors? (List name and address):

*Under collection or foreclosure? (List Agency name and address):

Will you reaffirm this debt?
13.Name:
Account #:
Address:

Date Incurred:
Amount Owed:
Description:
Fair Market Value of Property secured by this debt:
Type of Debt:
*Any Codebtors? (List name and address):

*Under collection or foreclosure? (List Agency name and address):

Will you reaffirm this debt?
14.Name:
Account #:
Address:

Date Incurred:
Amount Owed:
Description:
Fair Market Value of Property secured by this debt:
Type of Debt:
*Any Codebtors? (List name and address):

*Under collection or foreclosure? (List Agency name and address):

Will you reaffirm this debt?
15.Name:
Account #:
Address:

Date Incurred:
Amount Owed:
Description:
Fair Market Value of Property secured by this debt:
Type of Debt:
*Any Codebtors? (List name and address):

*Under collection or foreclosure? (List Agency name and address):

Will you reaffirm this debt?
16.Name:
Account #:
Address:

Date Incurred:
Amount Owed:
Description:
Fair Market Value of Property secured by this debt:
Type of Debt:
*Any Codebtors? (List name and address):

*Under collection or foreclosure? (List Agency name and address):

Will you reaffirm this debt?
17.Name:
Account #:
Address:

Date Incurred:
Amount Owed:
Description:
Fair Market Value of Property secured by this debt:
Type of Debt:
*Any Codebtors? (List name and address):

*Under collection or foreclosure? (List Agency name and address):

Will you reaffirm this debt?
18.Name:
Account #:
Address:

Date Incurred:
Amount Owed:
Description:
Fair Market Value of Property secured by this debt:
Type of Debt:
*Any Codebtors? (List name and address):

*Under collection or foreclosure? (List Agency name and address):

Will you reaffirm this debt?
19.Name:
Account #:
Address:

Date Incurred:
Amount Owed:
Description:
Fair Market Value of Property secured by this debt:
Type of Debt:
*Any Codebtors? (List name and address):

*Under collection or foreclosure? (List Agency name and address):

Will you reaffirm this debt?
20.Name:
Account #:
Address:

Date Incurred:
Amount Owed:
Description:
Fair Market Value of Property secured by this debt:
Type of Debt:
*Any Codebtors? (List name and address):

*Under collection or foreclosure? (List Agency name and address):

Will you reaffirm this debt?
21.Name:
Account #:
Address:

Date Incurred:
Amount Owed:
Description:
Fair Market Value of Property secured by this debt:
Type of Debt:
*Any Codebtors? (List name and address):

*Under collection or foreclosure? (List Agency name and address):

Will you reaffirm this debt?
22.Name:
Account #:
Address:

Date Incurred:
Amount Owed:
Description:
Fair Market Value of Property secured by this debt:
Type of Debt:
*Any Codebtors? (List name and address):

*Under collection or foreclosure? (List Agency name and address):

Will you reaffirm this debt?
23.Name:
Account #:
Address:

Date Incurred:
Amount Owed:
Description:
Fair Market Value of Property secured by this debt:
Type of Debt:
*Any Codebtors? (List name and address):

*Under collection or foreclosure? (List Agency name and address):

Will you reaffirm this debt?
24.Name:
Account #:
Address:

Date Incurred:
Amount Owed:
Description:
Fair Market Value of Property secured by this debt:
Type of Debt:
*Any Codebtors? (List name and address):

*Under collection or foreclosure? (List Agency name and address):

Will you reaffirm this debt?
*Are you a party (either as a plaintiff or defendant) to any lawsuit now pending or terminated within the past year?
Caption (-vs-) of Suit and Case Number:

Type of Suit:

Court & Location:

*Has any of your property (such as wages, bank accounts, or personal property) been attached, garnished, or seized under any legal procedure within the past year?
Caption (-vs-) of Suit and Case Number:

Date of Seizure:

Description and Value of Property:

*List all property that has been repossessed by a creditor, foreclosed, or returned to the seller within the past year.

Name & Address of Creditor:

Date of Repossession or Foreclosure:

*Have you made any transfers of your property for the benefit of your creditors within the past 120 days?

Name and Address of Assignee:

Date of Assignment:

Terms of Assignment or settlement:

*List all gifts over $200.00 or charitable contributions of $100.00 made within the past year:

Name & Address:

Relation to Debtor:

*List all payments made or property transferred to any persons within the past year for bankruptcy or debt counseling, consolidation, consultation or preparation.
Name and Address of Payee:

Date of Payment Name of Payor of other than Debtor:

Amount of Money or Description of Property & Value of Property:

*List all financial accounts that were closed, sold or transferred within the past year:
Name & Address of Financial Institution:

Account Number & Type:

Date of Closing and Final Balance:

*List all property owned by another person that the debtor holds or controls.
Name & Address of Owner:

Description & Value of Property:

Description & Value of Property:

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