Fields marked with an * are required First Name Last Name Address City State California Zip/Post Code Phone Email Marital Status Married Single Separated Divorced f Married or Divorced within last 8 years: Name of Spouse * Have you (or your spouse) used any other name or trade name in the last 6 years? Yes No Have you lived at your present address for the last 90 days? Yes No Have you (or your spouse) ever filed bankruptcy before? Yes No State Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware District of Columbia Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming Do you (or your spouse) owe any money as a result of a DUI or criminal fine? Yes No Do you (or your spouse) owe any money from a student loan or tuition? Yes No Do you (or your spouse) owe any money for past taxes to either the State or IRS? Yes No Are you (or your spouse) the beneficiary of anyone's will or trust Yes No Have you (or your spouse) paid back any family members or friends within the last year? Yes No Have you (or your spouse) sold, transferred, or given away any property within the last year? Yes No Do you (or your spouse) have the right to file or have filed a claim against anyone for money (including personal injury or workers compensation matters)? Yes No Has anyone obtained a judgment against (or your spouse) or have an active lawsuit pending? Yes No Are you (or your spouse) a co-signor for anyone's debt? Yes No Has anyone co-signed for any of your (or your spouse's) debt? Yes No If you own any Real Property (including raw land, timeshares or cematery plots) please list the address City Zip/Post Cod Do you (or your spouse) own any other real property? Yes No Name of the lender holding the first mortgage Is there a second mortgage or any other secured lien against this property? Yes No List the amount of cash on hand List the total in all bank checking and savings accounts List any amounts paid to anyone for a security deposit List the value of all household goods and furniture you (or your spouse) owns using a "yard sale" value List the value of all books and art List the value of all clothing List the value of all jewelry List the value of any guns, hobby or sports equipment List the value of any whole life or universal life insurance policies List the value of any annunities List the value of any stocks or bonds Do you (or your spouse) own any interest in a partnership or joint venture? Yes No Do you (or your spouse) receive alimony or support? Yes No Are you (or your spouse) entitled to a tax refund? Yes No Do you (or your spouse) own or hold any licenses or franchise agreements? Yes No How many vehicles do you (or your spouse) own? 1 2 3 More Do you (and your spouse) own any motorcycles, boats or aircraft? Yes No Do you (or your spouse) own any business equipment, tools or inventory? Yes No Does anyone owe you (or your spouse) any money? Yes No List your occupation Who do you work for: Employer's address Spouse's occupation Spouse's Employer's address How often are you paid? weekly bi-weekly semi-monthly monthly How often is your Spouse paid? weekly bi-weekly semi-monthly monthly Net income per pay period Spouse's Net income per pay period List your monthly expenses for: Rental / Mortgage Property Tax / Insurance Electricity / Heat / Water / Sewer / Trash Cable / Internet Home Repairs Food Personal Grooming / Care Clothing / Dry Cleaning Gas / Oil / Repairs for Vehicles Out of Pocket Medical Charitable Contributions Life Insurance Auto Insurance Other Insurance Taxes (not property tax or tax deducted from wages) Other Installment Payments Business Expenses Gross Income reported on last tax return Income received last year from sources other than wages / earnings Income received this year from sources other than wages / earnings Did you (or your spouse) pay anyone for bankruptcy services within the last year? Yes No Were you (or your spouse) a party to any lawsuits in the last year? Yes No Did you (or your spouse) lose any property as a result of theft or fire last year? Yes No Do you (or your spouse) have a safety deposit box? Yes No Have you (or your spouse) closed any bank accounts last year? Yes No Have you (or your spouse) a member of any corporation, LLC or partnership within the last 2 years? Yes No 1+5 SUBMIT
