Before your first visit, please complete and print the following questionnaire.
Remember to bring your Drivers License and Social Security Card with you.
Thank you.
TODAY'S DATE
Name
Social Sec. No.
Spouse
Address
City , State , Zip
County
Home Phone Cell Phone
E-mail Address
How long have you lived in this state?
Dependents? (Name & Age)
How did you find out about our firm?
PERSONAL INFORMATION
Occupation (You) (Spouse)
Work Phone No. (You) How Long?
Work Phone No. (Spouse) How Long?
Date of Birth
Marital Status: Married Single Separated Divorced
Name of Employer (You)
Name of Employer (Spouse)
Do you: Rent Own
Have you ever filed for bankruptcy or debt consolidation? yes no What year?
Are you behind in house or rent payments? yes no How many payments?
Do you owe taxes? yes no How much? IRS? State? County?
Are you expecting an income tax refund this Spring? yes no How much?
Do you owe student loans? yes no How many? How much?
Are you behind in child support or spousal support? yes no How much?
Do you have any outstanding NSF (non-sufficient funds) checks? yes no How much? Are any of the checks with check advance companies? yes no
NSF checks to a grocery store, department store or somebody else in exchange for goods and services must be taken care of by yourself.
SECURED DEBTS:
HOME LOANS:
1st MTG Pymnt $ /mo. Loan Total $ Behind? yes no How many? 2nd MTG Pymnt $ /mo. Loan Total $ Behind? yes no How many? 3rd MTG Pymnt $ /mo. Loan Total $ Behind? yes no How many?
What is the value of your home? What year did you purchase your home? Purchase Price?
Do you own or have any ownership interest in any other Real Estate? yes no Approximate value of property $ Year purchased Purchase price $
VEHICLES: Please list the year, make and model of ALL vehicles in your name or possession
1st Auto(yr,make,model): Paid For Buying Leasing Title Loan Mo. Pmnt. Balance
2nd Auto(yr,make,model): Paid For Buying Leasing Title Loan Mo. Pmnt. Balance
3rd Auto(yr,make,model): Paid For Buying Leasing Title Loan Mo. Pmnt. Balance
Are you behind on any car payments? Yes No How many? Date of most recent purchase
PLEASE LIST ALL OF YOUR CREDITORS - It is very important that you list ALL of your creditors.
If any of your debts have cosigners, codebtors, or somebody else may be liable for the debt, please let us know by placing a star (*) next to the name of the cosigned creditor and write down the co-signer's name.
..........Monthly Payment............... Total Amount............#Payments ..........Company.........Amount...........Owed (Balance)..........Behind
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Are your wages now being garnished or about to be garnished? yes no Give details:
Do you have any outstanding judgments against you?.... yes no Who? Do you have any pending lawsuits against you? ...... yes no Who?
APPROXIMATE INCOME & EXPENSES
TOTAL MONTHLY INCOME: $
Estimated Future Monthly Living Expenses:
Rent/Mortgage/Homeowners Assn./Space Rent Payment $
Utilities: Elec.& Gas Water Phone Cable $
Food $
Clothing $
Home Maintenance (including cleaning products) $
Laundry & Cleaning $
Newspapers, Magazines, Books (Including School Books) $
Medical, Dental & Medicines (excluding health insurance) $
Auto Insurance (per month) $
Other Insurance (not deducted from your paycheck) $
Auto operating costs - gas, oil & maintenance $
Child or Spousal Support $
Day Care $
1st Auto Payment $
2nd Auto Payment $
Other installment payments (specify) $
Other living expenses (specify) $
TOTAL MONTHLY EXPENSES: $
Have you listed all credit cards? yes no
Any cash advances in the last 12 months? yes no
Any gambling losses (casinos, bingo, sporting events)? yes no
Have you listed all furniture loans? yes no
Have you listed all outstanding medical bills? yes no
Are you current on utilities (phone, power, cable)? yes no
Have you cosigned a loan for anybody or are there any debts for which you have a cosigner? yes no
Do you have rent-to-own contracts, pawns, or check advance loans? yes no
Do you have any 401K, IRA, thrift-savings, or retirement plan loans? yes no
Have you transferred or sold any property recently? yes no