Do you own a home?	Yes     No If so, what is its value? $ Loan amount?  (All Loans) $ Do you currently have insurance? Yes     No Are you behind in your home payments? Yes     No If so, what is the total amount that you are behind? $
Do you own a car?	Yes     No If so, what is its value? $ Loan amount? $ Do you currently have insurance? Yes     No Are you behind in your car payments? Yes     No If so, what is the total amount that you are behind? $
Have you filed your income tax returns for 2004 and all prior years?	Yes     No If you have unfiled tax returns, please list the years in which you have not filed tax returns.
Do you own any income taxes?	Yes     No If so, please list the years and amounts owed.
How much do you owe on credit cards?	$
How much do you owe on medical bills?	$
Are you currently being contacted by debt collectors?	Yes     No
Total Unsecured Debt You Have?	$ A rough estimate of the total is okay.  Unsecured debts are debts like credit cards, medical bills, finance companies, and personal loans where none of your property listed as "collateral."
Total Monthly Minimum Payments?	$ If you had the money to pay on all your unsecured debts on time each month, how much would the minimum payments add up to.  Just give us an approximate amount.  Is it $300 per month?  $500 per month?  $1,000 per month?  More?
Do you owe any student loans?	Yes     No If so, how much do you owe?
Do you owe any Traffic Tickets, Criminal Fines or Restitution?	Yes     No If so, how much do you owe?
Are you behind in your Maintenance, Alimony or Child Support payments?	Yes     No If so, how much do you owe?
Please tell us a little about your financial situation.
What are your biggest financial problems?
What would you like to see happen?