we are a law firm providing debt relief services to ...€¦ · has any of your and/or your...

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⃝ Husband’s paystubs

⃝ Wife’s paystubs ⃝ 2018 IRS

⃝ COC ⃝ 2017 IRS

William W. Pepper ∙ Andrew S. Nason· Daniel T. Lattanzi · Emmett W. Pepper

Attorneys at Law 8 Hale Street Charleston, West Virginia 25301 Phone (304) 346-0361 Fax (304) 346-1054

WE ARE A LAW FIRM PROVIDING DEBT RELIEF SERVICES TO

INDIVIDUALS FILING FOR BANKRUPTCY PROTECTION

Your full legal name: ________________________________________________AGE_______SSN:______ - ____ - _______ (First) (Full Middle Name) (Last) (Social Security Number) Spouse’s full legal name: _______________________________________________ AGE_______SSN:______ - ____ - _______ (First) (Full Middle Name) (Last) (Social Security Number) Marital Status (Circle One): Single Married Separated Divorced Widow(er)

All other names you or your spouse have used in the last 6 years: __________________________________

Residential address: Mailing address: ________________________________________ _________________________________________ ________________________________________ _________________________________________ What state did you live in 27 months ago? _________________ What county?___________________________

Have you lived there for at least ninety (90) days? ______________________

Home phone no: (_____) _____________________

Your work phone no: (_____) ___________________ Your cell no: (_____) ____________________________

Spouse’s work no: (_____) _____________________ Spouse’s cell no: (_____) _________________________

All other addresses either of you have had in the last 6 years: ____________________ ___________________________________________________________________________________ ___________________________________________________________________________________ Have you or your spouse ever filed bankruptcy before? ____________ If yes: Who? __________________________ When? _______________ Where? ______________________________

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Do you and/or your spouse own any real estate? ____________ If yes, describe it: (include the size of the land, location, what type of buildings and the current use.) ___________________________________________________________________________________

___________________________________________________________________________________

___________________________________________________________________________________

___________________________________________________________________________________

___________________________________________________________________________________

What name or names are on the deed of this property? _______________________________________

If you are unsure, feel free to bring a copy of the deed with you.

Do you and/or your spouse owe for the purchase of this real estate? ___________________________________

If yes, what bank(s) or person(s) hold the mortgage(s)? _____________________________________________

What year did you and/or your spouse buy or begin paying for this property? ____________________________

What was the purchase price? $_______________When was it last appraised? ___________________________

What was the appraised value? $__________How much, if any, is owed on the property? $_________________

How much do you think the property is worth? $________________________

Are there any other liens on the real estate besides the mortgage? __________

Do you and/or your spouse own any OTHER real estate? ____________ If yes, describe it: (include the size of the land, location, what type of buildings and the current use.) ___________________________________________________________________________________

___________________________________________________________________________________

___________________________________________________________________________________

___________________________________________________________________________________

___________________________________________________________________________________

What name or names are on the deed of this property? _______________________________________

If you are unsure, feel free to bring a copy of the deed with you.

Do you and/or your spouse owe for the purchase of this real estate? ___________________________________

If yes, what bank(s) or person(s) hold the mortgage(s)? _____________________________________________

What year did you and/or your spouse buy or begin paying for this property? ____________________________

What was the purchase price? $_______________When was it last appraised? ___________________________

What was the appraised value? $______________How much, if any, is owed on the property? ______________

How much do you think the property is worth? $________________________

Are there any other liens on the real estate besides the mortgage? __________

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Do you or your spouse own any motor vehicles? _________ If yes, list each and its value: ______________________________________________ $________________ $_________________ Year Make (ex: Ford) Model (ex: Mustang) Suffix (ex: GT) Value Amount Owed

Mileage _____________ Problems (rust, mechanical, etc.) or options (V8, convertible, etc.) __________________________ What name(s) are on the title (same as glove box registration card)? ______________________________________________ =========================================================================

______________________________________________ $________________ $_________________ Year Make (ex: Ford) Model (ex: Mustang) Suffix (ex: GT) Value Amount Owed


______________________________________________ $________________ $_________________ Year Make (ex: Ford) Model (ex: Mustang) Suffix (ex: GT) Value Amount Owed


Which of the above vehicle(s), if any, are owned free & clear of any liens? _______________________________

==========================================================================

Do you have the title(s)? _________ If not, bring your car loan papers with you.

Do you and/or your spouse own any mobile homes? ____________

If yes, list the year, make, model & value: __________________________________________ $_______________ $_________________ (Year) (Make) (Model) (Value) (Amount Owed) Is/are the above mobile home(s) owned free & clear of any liens? _____________

If no, what bank or person holds the lien(s)? ______________________________________________________

Attorney Notes:

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List below everything that you and/or your spouse own and what each item’s current market value is in used condition. “Market Value” means what you could go out and buy it for right now if you wanted to from a merchant selling item of like age and like condition. You must include every item you own now even if you still owe money on it. You may group items together such as living room suite, bedroom suite, so you do not have to list each and every table, lamp, etc., but we must have a complete list of everything in your house. You do not have to list each small item such as garbage can, hair dryers, etc., as these items can be listed as miscellaneous household goods or miscellaneous personal possessions. Bank Accounts Exercise Equipment Cash Value of Insurance Policy Utility & Rent Deposits Boats, Etc. Household Goods & Furniture Pets, Farm Animals

Inventory Farm Supplies Sporting Equipment & Implements Clothing Guns, Etc. Art Objects Electronics (computer, phones, etc.)

Office Equipment & Supplies Motorcycles/ATVs Collections Jewelry Stocks & Bonds Pension/Retirement Plans Cryptocurrency (Bitcoin, etc.)

Items Values ____________________________________

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Items Values ____________________________________

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Does anyone else have anything that belongs to you and/or your spouse or that you and/or your spouse own some

interest in? If yes, explain: ____________________________________________________________________

___________________________________________________________________________________

Are you and/or your spouse holding any property or money that belongs to someone else? ___________________

If yes, explain: _______________________________________________________________________________

____________________________________________________________________________________ Please state the name and age of any minor children or dependents you and/or your spouse have: Name Age _______________________________________ _______________________________________

Name Age _______________________________________ _______________________________________

Do you and/or your spouse receive any child support or government assistance income for any of these children or dependents? _______If yes, state what kind of income and amount received: Source of Income: ______________________________________ Amount per month: ___________________

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Are you working now? ___________ What is your job title? __________________________________________

By whom are you employed? __________________________________________________________________

Employer’s address: __________________________________________________________________________ If payroll checks are issued from address other than above, please list name and address of payroll department. You must list this address if you want to stop a wage garnishee: ____________________________________________________________________________________ (Company Name) (Street or Post Office Box) ____________________________________________________________________________________ (City & State) (Zip Code) How many years have you worked there? _______________ How often are you paid? _____________________

AT YOUR INITIAL APPOINTMENT YOU WILL NEED TO BRING COPIES OF EVERY PAY STUB

YOU RECEIVED IN THE LAST 7 MONTHS

GROSS PAY PER PERIOD: ...…….……………$__________________________________

PAYROLL TAXES & SOCIAL SECURITY: …. $__________________________________

INSURANCE: ...…………………………………$__________________________________

UNION DUES: ...…………..……………………$__________________________________

RETIREMENT: ……………………….….……...$__________________________________

OTHER DEDUCTIONS: …………….….……….$__________________________________

TAKE HOME PAY: …………………………......$__________________________________

If you are not working now, please state what type of income, if any, you are receiving now and the monthly amount you are receiving. Example: Unemployment - $500; Welfare - $200. Source of Income: __________________________________ Amount per month: _________________________ Please list an estimate or your yearly income from employment for the past two years. 2016 $___________________________ _______________________________________________

(Gross Amount) (List Employers) 2017 $___________________________ _______________________________________________

(Gross Amount) (List Employers) 2018 Year-to-date $________________ _______________________________________________

(Gross Amount) (List Employers)

(NOTE: WE WILL NEED YOU TO PROVIDE COPY OF YOUR LAST TWO (2) IRS TAX RETURNS IF YOU HAVE THEM.)

What amount of income have you received from other sources during each of the past two years? Example: Unemployment, Welfare, Workers’ Compensation. 2016 $___________________________ _______________________________________________

(Gross Amount) (Source) 2017 $___________________________ _______________________________________________

(Gross Amount) (Source) 2018 Year-to-date $________________ _______________________________________________

(Gross Amount) (Source)

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Is your spouse working now? ______________What is his/her job title? _________________________________ By whom is your spouse employed? ______________________________________________________________ Employer’s address: __________________________________________________________________________ If payroll checks are issued from address other than above, please list name and address of payroll department. You must list this address if you want to stop a wage garnishee. ____________________________________________________________________________________ (Company Name) (Street Or Post Office Box) ____________________________________________________________________________________ (City & State) (Zip Code) How long has your spouse worked there? ___________ How often is your spouse paid? ____________________ AT YOUR INITIAL APPOINTMENT YOU WILL NEED TO BRING COPIES OF EVERY PAY STUB

YOU RECEIVED IN THE LAST 7 MONTHS

GROSS PAY PER PERIOD: ………………….$__________________________________

PAYROLL TAXES & SOCIAL SECURITY: ..$__________________________________

INSURANCE:……..…………………………..$__________________________________

UNION DUES:……….……………….……….$__________________________________

RETIREMENT: ………………….……………$__________________________________

OTHER DEDUCTIONS:………………..…….$__________________________________

TAKE HOME PAY:…………………………..$__________________________________

If your spouse is not working now, please state what type of income, if any, he/she is receiving now and the monthly amount received. Example: Unemployment - $500; Welfare - $200. Source of Income: _______________________________ Amount per month: ___________________________ Please list an estimate or your yearly income from employment for the past two years. 2016 $___________________________ _______________________________________________

(Gross Amount) (List Employers) 2017 $___________________________ _______________________________________________

(Gross Amount) (List Employers) 2018 Year-to-date $________________ _______________________________________________

(Gross Amount) (List Employers)

(NOTE: WE WILL NEED YOU TO PROVIDE COPY OF YOUR LAST TWO (2) IRS TAX RETURNS IF YOU HAVE THEM.)

What amount of income have you received from other sources during each of the past two years? Example: Unemployment, Welfare, Workers’ Compensation. 2016 $___________________________ _______________________________________________

(Gross Amount) (Source) 2017 $___________________________ _______________________________________________

(Gross Amount) (Source) 2018 Year-to-date $________________ _______________________________________________

(Gross Amount) (Source)

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Have you or your spouse been self-employed or in business for yourself or with a partner in the last 6

years? ___________If yes, please list: Name and address of the company or person: ______________________

____________________________________________________________________________________

____________________________________________________________________________________ (Street or Post Office Box) (City & State) (Zip Code) When month/year was the business started? ________________ When did it end? _________________________

What was the nature of the business? _____________________________________________________________

Who was involved in the business? ______________________________________________________________ (You?) (Your spouse?) Please state the name and address of the person or company that kept the records on your business: ___________________________________________________________________________________________ Who has possession of these records? ___________________________________________________________ What tax refunds have you or your spouse received in the past year? Federal: $_________________________________ State: $______________________________________ Do you owe taxes now? ______________________ If yes, how much do you owe the IRS? $ ________________________ _______________________________

(Amount) (Year(s) owed) If yes, how much do you owe the state? $ ________________________ _______________________________

(Amount) (Year(s) owed)

Are you expecting to receive a tax refund the next time you file your tax returns? _________________________ If so, how much? Federal: $_________________________________ State: $_______________________________________ Please list all checking and savings accounts you and/or your spouse have had in the past two years (whether open or closed). NAME OF BANK TYPE OF ACCOUNT NAMES ON ACCOUNT (Checking or Savings) (Open or Closed) _________________________ ________________________ ________________________ _________________________ ________________________ ________________________ _________________________ ________________________ ________________________ Have you had any safe deposit boxes in the last two years? _____________ If yes, please state the name of the bank and their address: ____________________________________________ (Name of Bank) ____________________________________________________________________________________

(Address of Bank)

Do you still have the box? __________ What is in it? ________________________________________________

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Do you and/or your spouse have any lawsuits or claims pending against anyone? ____________If yes, please

explain: ____________________________________________________________________________________

Who is your lawyer on this claim? ______________________________ (phone no.)_______________________ Have any lawsuits been filed against you and/or your spouse in the last 12 months? ________If yes,

please bring in any papers you have received on it as well as answer the following:

Who sued you? ________________________________________________________________________

In what court & county where you sued? _____________________________________________________

Why where you sued? (money owed, car, etc.): ________________________________________________

____________________________________________________________________________________

Was judgment rendered? _________________________________________________________________

Is there any other real estate or personal property that you and/or your spouse own or have an interest in

that you have not told us about?__________ If yes, explain:_______________________________________

___________________________________________________________________________________ Has any of your and/or your spouse’s property been attached or taken by the sheriff in the last four

months?_________ If yes, list what was attached or taken:________________________________________

____________________________________________________________________________________ Has anything been repossessed from you and/or your spouse in the last year? _____________________________

If yes, what was it? _____________________________________________________________________

When was it taken? ______________________________________________________________________

Name and address of lender/bank who took it: _________________________________________________

____________________________________________________________________________________ PLEASE PROVIDE COPIES OF ALL PAPERWORK ON CAR PURCHASES THAT WERE FINANCED.

Have you and/or your spouse’s wages been garnished in the past three months? _________________________ If the garnishee was with a former employer, please list the name and address of the former employer: ____________________________________________________________________________________ ____________________________________________________________________________________ (Note: If your wages were garnisheed within the last three months, please bring to the office appointment any

documents you have regarding the garnishee, including the notice for the court, plus any pay stubs showing the sums

deducted.)

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Besides normal Christmas, birthday gifts, etc., have you and/or your spouse made any gifts to anyone in the past

year? ________ If yes, explain to whom and what: ______________________________________________

____________________________________________________________________________________

YOU MUST ANSWER THIS QUESTION IN WRITING: Have you and/or your spouse sold or transferred anything valuable to anyone in the last year? ________________

If yes, explain fully:

____________________________________________________________________________________

____________________________________________________________________________________

___________________________________________________________________________________

____________________________________________________________________________________

YOU MUST ANSWER THIS QUESTION IN WRITING:

Have you and/or your spouse sold or transferred anything valuable to any relative or family member in

the last four years? If yes, explain fully. If real estate, bring a copy of the deed:

____________________________________________________________________________________

____________________________________________________________________________________

____________________________________________________________________________________

Have you and/or your spouse lost anything by fire, theft, or gambling in the last year? ________ If yes,

explain fully: _______________________________________________________________________________

___________________________________________________________________________________

___________________________________________________________________________________

If yes, was the loss covered by insurance? _______ If yes, list the name of the insurance company and amount

paid to you and/or your spouse for the loss: _______________________________________________________

__________________________________________________________________________________________

__________________________________________________________________________________________

Have you and/or your spouse given anything or any money to an attorney in the past year? __________________ If yes, explain to whom, how much and why: ______________________________________________________

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Your monthly take-home pay: ...................................... $_________________

Spouse’s monthly take home pay: ................................ $_________________

Rent/mortgage payment(s) ........................................... $_________________

Utilities: Electric……………… ................................. $_________________ Gas/Heating Oil ……………… ................... $_________________ Water & Sewer ………………. ................... $_________________

Garbage……………………….…….………$_________________ Land Phone $___________ Cell Phone(s)……....$_________________ TV Cable $___________ Internet……….….…$_________________ Home Maintenance (yearly divided by 12)…….……..$_________________

Food…………………………………………………...$_________________

Clothing ........................................................................ $_________________ Misc. Expenses:

Daycare/Babysitting ........................................ $_________________ Haircuts, grooming .......................................... $_________________ Pet expenses (food & vet)................................ $_________________ Tobacco ........................................................... $_________________ Home security system ..................................... $_________________ Storage unit fee ................................................ $_________________ Laundry & dry cleaning................................... $_________________ ___________________ ................................... $_________________

Medical & dental (yearly divided by 12) ...................... $_________________

Transportation (gas, oil, repair) .................................... $_________________

Recreation, clubs, subscriptions & entertainment ........ $_________________

Charitable contributions (church, etc.) ......................... $_________________

Insurance: Homeowners ................... $_________________ Put NA if in escrow Life .................................. $_________________ Health .............................. $_________________ Auto ................................ $_________________ Other (Dental/Optical) .... $_________________

Taxes: Real estate (divide yearly by 12) ....... $_________________ Put NA if in escrow Personal (vehicles–divide

yearly by 12) ................... $_________________ Monthly payments: Which vehicle? How many payments left?

Auto #1 $___________________ _____________________ _________

Auto #2 $___________________ _____________________ _________

Auto #3 $___________________ _____________________ _________

Furniture/Appliances $___________________ _________

Student loans $___________________ _________

Other (specify) $___________________ _________

Alimony, child support paid to others ………………. $___________________

Payments for support of people Name of person(s)

not living in your house $_________________ ___________________________________________

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CREDITOR LIST YOU MUST LIST EACH AND EVERY DEBT YOU OWE EVEN IF YOU INTEND TO CONTINUE TO PAY FOR IT.

PLEASE LIST SECURED DEBTS FIRST. EXAMPLE – DEBTS SECURED BY HOUSE, CAR, BOAT, ATV, FURNITURE, JEWELRY, ETC.

NAME OF CREDITOR EXACT AND COMPLETE MAILING ADDRESS EST. YEAR(S) OF DEBT DESCRIPTION OF DEBT MONTHLY PAYMENT

ESTIMATED TOTAL OWED

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Pepper & Nason

8 Hale Street Charleston, WV 25301

Telephone: 304-346-0361

From I-64 East/Corridor G (from Logan, Lincoln or Boone Counties): Take the Virginia Street exit. Bear right at the end of the exit ramp and turn right onto Virginia Street. Stay in the right hand lane until you reach Hale Street (approximately 5 blocks. Once you pass Bank One, you are getting close to Hale Street.)*

From I-64 West/I-77 North (from Beckley, Lewisburg, etc): Take the Kanawha Boulevard exit. You will go approximately 2.50 miles. Turn right onto Hale Street just after passing Charleston Newspapers and going underneath the bridge. If you get as far as Capitol Street or the new riverfront park, you have missed us.*

From I-77 South/I-79 South (from Parkersburg, Jackson County, Clarksburg, etc): Take the Washington Street exit. Turn left at third light onto Virginia Street. Get in the right hand lane until you reach Hale Street (approximately 4 blocks). Once you pass Chase Bank, you are getting close to Hale Street).* * We are a two story brick building – there is a sign on the Hale Street side of the building. We have limited parking beside our building for clients. If you wish to see if there might be a spot available, from Virginia Street turn right just past Hale Street between the building on the corner and the South Side Bridge. From the Boulevard onto Hale Street, turn right on Virginia Street and make an immediate right before crossing the South Side Bridge.

First: Full Middle Name: Last: AGE: SSN: undefined: undefined_2: First_2: Full Middle Name_2: Last_2: AGE_2: SSN_2: undefined_3: undefined_4: All other names you or your spouse have used in the last 6 years: Residential address 1: Residential address 2: Mailing address 1: Mailing address 2: What state did you live in 27 months ago: What county: Have you lived there for at least ninety 90 days: undefined_5: undefined_6: Your work phone no: undefined_7: Your cell no: undefined_8: Spouses work no: undefined_9: Spouses cell no: undefined_10: All other addresses either of you have had in the last 6 years 1: All other addresses either of you have had in the last 6 years 2: All other addresses either of you have had in the last 6 years 3: Have you or your spouse ever filed bankruptcy before: Who: When: Where: Do you andor your spouse own any real estate: location what type of buildings and the current use 1: location what type of buildings and the current use 2: location what type of buildings and the current use 3: location what type of buildings and the current use 4: location what type of buildings and the current use 5: What name or names are on the deed of this property: Do you andor your spouse owe for the purchase of this real estate: If yes what banks or persons hold the mortgages: What year did you andor your spouse buy or begin paying for this property: What was the purchase price: When was it last appraised: What was the appraised value: How much if any is owed on the property: How much do you think the property is worth: Are there any other liens on the real estate besides the mortgage 1: Are there any other liens on the real estate besides the mortgage 2: Do you andor your spouse own any OTHER real estate: the land location what type of buildings and the current use 1: the land location what type of buildings and the current use 2: the land location what type of buildings and the current use 3: the land location what type of buildings and the current use 4: the land location what type of buildings and the current use 5: What name or names are on the deed of this property_2: Do you andor your spouse owe for the purchase of this real estate_2: If yes what banks or persons hold the mortgages_2: What year did you andor your spouse buy or begin paying for this property_2: What was the purchase price_2: When was it last appraised_2: What was the appraised value_2: How much if any is owed on the property_2: How much do you think the property is worth_2: Are there any other liens on the real estate besides the mortgage: Do you or your spouse own any motor vehicles 1: Do you or your spouse own any motor vehicles 2: Do you or your spouse own any motor vehicles 3: Do you or your spouse own any motor vehicles 4: Do you or your spouse own any motor vehicles 5: undefined_11: undefined_12: Mileage: Problems rust mechanical etc or options V8 convertible etc: What names are on the title same as glove box registration card: Year: Make ex Ford: Model ex Mustang: Suffix ex GT: undefined_13: undefined_14: Mileage_2: Problems rust mechanical etc or options V8 convertible etc_2: What names are on the title same as glove box registration card_2: Year_2: Make ex Ford_2: Model ex Mustang_2: Suffix ex GT_2: undefined_15: undefined_16: Mileage_3: Problems rust mechanical etc or options V8 convertible etc_3: What names are on the title same as glove box registration card_3: Which of the above vehicles if any are owned free clear of any liens: Do you have the titles: Do you andor your spouse own any mobile homes: Year_3: Make: Model: undefined_17: undefined_18: Isare the above mobile homes owned free clear of any liens: If no what bank or person holds the liens: Items 1: Items 2: Items 3: Items 4: Items 5: Items 6: Items 7: Items 1_2: Items 2_2: Items 3_2: Items 4_2: Items 5_2: Items 6_2: Items 7_2: Does anyone else have anything that belongs to you andor your spouse or that you andor your spouse own some: interest in If yes explain: undefined_19: Are you andor your spouse holding any property or money that belongs to someone else: If yes explain: Name 1: Name 2: Name 1_2: Name 2_2: Do you andor your spouse receive any child support or government assistance income for any of these children: If yes state what kind of income and amount received: Amount per month: Are you working now: What is your job title: By whom are you employed: Employers address: Company Name: Street or Post Office Box: City State: Zip Code: How many years have you worked there: How often are you paid: undefined_20: PAYROLL TAXES SOCIAL SECURITY: undefined_21: undefined_22: undefined_23: undefined_24: undefined_25: Source of Income: Amount per month_2: undefined_26: List Employers: undefined_27: List Employers_2: Yeartodate: List Employers_3: undefined_28: Source: undefined_29: Source_2: Yeartodate_2: Source_3: Is your spouse working now: What is hisher job title: By whom is your spouse employed: Employers address_2: Company Name_2: Street Or Post Office Box: City State_2: Zip Code_2: How long has your spouse worked there: How often is your spouse paid: undefined_30: PAYROLL TAXES SOCIAL SECURITY_2: undefined_31: undefined_32: undefined_33: undefined_34: undefined_35: Source of Income_2: Amount per month_3: undefined_36: List Employers_4: undefined_37: List Employers_5: Yeartodate_3: List Employers_6: undefined_38: Source_4: undefined_39: Source_5: Yeartodate_4: Source_6: Have you or your spouse been selfemployed or in business for yourself or with a partner in the last 6: If yes please list Name and address of the company or person: years 1: years 2: City State_3: Zip Code_3: When monthyear was the business started: What was the nature of the business: Please state the name and address of the person or company that kept the records on your business: undefined_40: Who has possession of these records: What tax refunds have you or your spouse received in the past year: State: Do you owe taxes now: If yes how much do you owe the IRS: undefined_41: Amount: Years owed: Years owed_2: If so how much: State_2: NAME OF BANK 1: NAME OF BANK 2: NAME OF BANK 3: Checking or Savings Open or Closed 1: Checking or Savings Open or Closed 2: Checking or Savings Open or Closed 3: NAMES ON ACCOUNT 1: NAMES ON ACCOUNT 2: NAMES ON ACCOUNT 3: Have you had any safe deposit boxes in the last two years: If yes please state the name of the bank and their address: Name of Bank: Do you still have the box: Address of Bank: Do you andor your spouse have any lawsuits or claims pending against anyone: explain: Who is your lawyer on this claim 1: Who is your lawyer on this claim 2: phone no: Have any lawsuits been filed against you andor your spouse in the last 12 months: Who sued you: In what court county where you sued: Why where you sued money owed car etc 1: Why where you sued money owed car etc 2: Was judgment rendered 1: Was judgment rendered 2: that you have not told us about 1: that you have not told us about 2: If yes explain_2: months 1: months 2: If yes list what was attached or taken: Has anything been repossessed from you andor your spouse in the last year: If yes what was it: When was it taken: Name and address of lenderbank who took it 1: Name and address of lenderbank who took it 2: PLEASE PROVIDE COPIES OF ALL PAPERWORK ON CAR PURCHASES THAT WERE FINANCED: Have you andor your spouses wages been garnished in the past three months: If the garnishee was with a former employer please list the name and address of the former employer 1: If the garnishee was with a former employer please list the name and address of the former employer 2: Besides normal Christmas birthday gifts etc have you andor your spouse made any gifts to anyone in the past: If yes explain to whom and what: year 1: year 2: Have you andor your spouse sold or transferred anything valuable to anyone in the last year: If yes explain fully 1: If yes explain fully 2: the last four years If yes explain fully If real estate bring a copy of the deed 1: the last four years If yes explain fully If real estate bring a copy of the deed 2: the last four years If yes explain fully If real estate bring a copy of the deed 3: If yes: Have you andor your spouse lost anything by fire theft or gambling in the last year: explain fully 1: explain fully 2: If yes was the loss covered by insurance: If yes list the name of the insurance company and amount: paid to you andor your spouse for the loss 1: paid to you andor your spouse for the loss 2: undefined_42: Have you andor your spouse given anything or any money to an attorney in the past year: undefined_43: undefined_44: undefined_45: undefined_46: undefined_47: undefined_48: undefined_49: Land Phone: undefined_50: undefined_51: undefined_52: undefined_53: undefined_54: undefined_55: undefined_56: undefined_57: undefined_58: undefined_59: undefined_60: undefined_61: undefined_62: undefined_63: undefined_64: undefined_65: undefined_66: undefined_67: undefined_68: undefined_69: undefined_70: undefined_71: undefined_72: Other DentalOptical: undefined_73: undefined_74: undefined_75: undefined_76: undefined_77: Which vehicle 1: Which vehicle 2: Which vehicle 3: undefined_78: undefined_79: undefined_80: How many payments left 1: How many payments left 2: How many payments left 3: How many payments left 4: How many payments left 5: How many payments left 6: undefined_81: undefined_82: Name of persons: NAME OF CREDITORRow1: EXACT AND COMPLETE MAILING ADDRESSK LG A: EXACT AND COMPLETE MAILING ADDRESSK LG A_2: EST YEARS OF DEBTRow1: DESCRIPTION OF DEBTRow1: MONTHLY PAYMENTRow1: ESTIMATED TOTAL OWEDRow1: NAME OF CREDITORRow2: EXACT AND COMPLETE MAILING ADDRESSK LG A_3: EXACT AND COMPLETE MAILING ADDRESSK LG A_4: EST YEARS OF DEBTRow2: DESCRIPTION OF DEBTRow2: MONTHLY PAYMENTRow2: ESTIMATED TOTAL OWEDRow2: NAME OF CREDITORRow3: EXACT AND COMPLETE MAILING ADDRESSK LG A_5: EXACT AND COMPLETE MAILING ADDRESSK LG A_6: EST YEARS OF DEBTRow3: DESCRIPTION OF DEBTRow3: MONTHLY PAYMENTRow3: ESTIMATED TOTAL OWEDRow3: NAME OF CREDITORRow4: EXACT AND COMPLETE MAILING ADDRESSK LG A_7: EXACT AND COMPLETE MAILING ADDRESSK LG A_8: EST YEARS OF DEBTRow4: DESCRIPTION OF DEBTRow4: MONTHLY PAYMENTRow4: ESTIMATED TOTAL OWEDRow4: NAME OF CREDITORRow5: EXACT AND COMPLETE MAILING ADDRESSK LG A_9: EXACT AND COMPLETE MAILING ADDRESSK LG A_10: EST YEARS OF DEBTRow5: DESCRIPTION OF DEBTRow5: MONTHLY PAYMENTRow5: ESTIMATED TOTAL OWEDRow5: NAME OF CREDITORRow6: EXACT AND COMPLETE MAILING ADDRESSK LG A_11: EXACT AND COMPLETE MAILING ADDRESSK LG A_12: EST YEARS OF DEBTRow6: DESCRIPTION OF DEBTRow6: MONTHLY PAYMENTRow6: ESTIMATED TOTAL OWEDRow6: NAME OF CREDITORRow7: EXACT AND COMPLETE MAILING ADDRESSK LG A_13: EXACT AND COMPLETE MAILING ADDRESSK LG A_14: EST YEARS OF DEBTRow7: DESCRIPTION OF DEBTRow7: MONTHLY PAYMENTRow7: ESTIMATED TOTAL OWEDRow7: NAME OF CREDITORRow8: EXACT AND COMPLETE MAILING ADDRESSK LG A_15: EXACT AND COMPLETE MAILING ADDRESSK LG A_16: EST YEARS OF DEBTRow8: DESCRIPTION OF DEBTRow8: MONTHLY PAYMENTRow8: ESTIMATED TOTAL OWEDRow8: NAME OF CREDITORRow9: EXACT AND COMPLETE MAILING ADDRESSK LG A_17: EXACT AND COMPLETE MAILING ADDRESSK LG A_18: EST YEARS OF DEBTRow9: DESCRIPTION OF DEBTRow9: MONTHLY PAYMENTRow9: ESTIMATED TOTAL OWEDRow9: NAME OF CREDITORRow10: EXACT AND COMPLETE MAILING ADDRESSK LG A_19: EXACT AND COMPLETE MAILING ADDRESSK LG A_20: EST YEARS OF DEBTRow10: DESCRIPTION OF DEBTRow10: MONTHLY PAYMENTRow10: ESTIMATED TOTAL OWEDRow10: NAME OF CREDITORRow11: EXACT AND COMPLETE MAILING ADDRESSK LG A_21: EXACT AND COMPLETE MAILING ADDRESSK LG A_22: EST YEARS OF DEBTRow11: DESCRIPTION OF DEBTRow11: MONTHLY PAYMENTRow11: ESTIMATED TOTAL OWEDRow11: NAME OF CREDITORRow12: EXACT AND COMPLETE MAILING ADDRESSK LG A_23: EXACT AND COMPLETE MAILING ADDRESSK LG A_24: EST YEARS OF DEBTRow12: DESCRIPTION OF DEBTRow12: MONTHLY PAYMENTRow12: ESTIMATED TOTAL OWEDRow12: NAME OF CREDITORRow13: EXACT AND COMPLETE MAILING ADDRESSK LG A_25: EXACT AND COMPLETE MAILING ADDRESSK LG A_26: EST YEARS OF DEBTRow13: DESCRIPTION OF DEBTRow13: MONTHLY PAYMENTRow13: ESTIMATED TOTAL OWEDRow13: NAME OF CREDITORRow14: EXACT AND COMPLETE MAILING ADDRESSK LG A_27: EXACT AND COMPLETE MAILING ADDRESSK LG A_28: EST YEARS OF DEBTRow14: DESCRIPTION OF DEBTRow14: MONTHLY PAYMENTRow14: ESTIMATED TOTAL OWEDRow14: NAME OF CREDITORRow1_2: EXACT AND COMPLETE MAILING ADDRESSK LG A_29: EXACT AND COMPLETE MAILING ADDRESSK LG A_30: EST YEARS OF DEBTRow1_2: DESCRIPTION OF DEBTRow1_2: MONTHLY PAYMENTRow1_2: ESTIMATED TOTAL OWEDRow1_2: NAME OF CREDITORRow2_2: EXACT AND COMPLETE MAILING ADDRESSK LG A_31: EXACT AND COMPLETE MAILING ADDRESSK LG A_32: EST YEARS OF DEBTRow2_2: DESCRIPTION OF DEBTRow2_2: MONTHLY PAYMENTRow2_2: ESTIMATED TOTAL OWEDRow2_2: NAME OF CREDITORRow3_2: EXACT AND COMPLETE MAILING ADDRESSK LG A_33: EXACT AND COMPLETE MAILING ADDRESSK LG A_34: EST YEARS OF DEBTRow3_2: DESCRIPTION OF DEBTRow3_2: MONTHLY PAYMENTRow3_2: ESTIMATED TOTAL OWEDRow3_2: NAME OF CREDITORRow4_2: EXACT AND COMPLETE MAILING ADDRESSK LG A_35: EXACT AND COMPLETE MAILING ADDRESSK LG A_36: EST YEARS OF DEBTRow4_2: DESCRIPTION OF DEBTRow4_2: MONTHLY PAYMENTRow4_2: ESTIMATED TOTAL OWEDRow4_2: NAME OF CREDITORRow5_2: EXACT AND COMPLETE MAILING ADDRESSK LG A_37: EXACT AND COMPLETE MAILING ADDRESSK LG A_38: EST YEARS OF DEBTRow5_2: DESCRIPTION OF DEBTRow5_2: MONTHLY PAYMENTRow5_2: ESTIMATED TOTAL OWEDRow5_2: NAME OF CREDITORRow6_2: EXACT AND COMPLETE MAILING ADDRESSK LG A_39: EXACT AND COMPLETE MAILING ADDRESSK LG A_40: EST YEARS OF DEBTRow6_2: DESCRIPTION OF DEBTRow6_2: MONTHLY PAYMENTRow6_2: ESTIMATED TOTAL OWEDRow6_2: NAME OF CREDITORRow7_2: EXACT AND COMPLETE MAILING ADDRESSK LG A_41: EXACT AND COMPLETE MAILING ADDRESSK LG A_42: EST YEARS OF DEBTRow7_2: DESCRIPTION OF DEBTRow7_2: MONTHLY PAYMENTRow7_2: ESTIMATED TOTAL OWEDRow7_2: NAME OF CREDITORRow8_2: EXACT AND COMPLETE MAILING ADDRESSK LG A_43: EXACT AND COMPLETE MAILING ADDRESSK LG A_44: EST YEARS OF DEBTRow8_2: DESCRIPTION OF DEBTRow8_2: MONTHLY PAYMENTRow8_2: ESTIMATED TOTAL OWEDRow8_2: NAME OF CREDITORRow9_2: EXACT AND COMPLETE MAILING ADDRESSK LG A_45: EXACT AND COMPLETE MAILING ADDRESSK LG A_46: EST YEARS OF DEBTRow9_2: DESCRIPTION OF DEBTRow9_2: MONTHLY PAYMENTRow9_2: ESTIMATED TOTAL OWEDRow9_2: NAME OF CREDITORRow10_2: EXACT AND COMPLETE MAILING ADDRESSK LG A_47: EXACT AND COMPLETE MAILING ADDRESSK LG A_48: EST YEARS OF DEBTRow10_2: DESCRIPTION OF DEBTRow10_2: MONTHLY PAYMENTRow10_2: ESTIMATED TOTAL OWEDRow10_2: NAME OF CREDITORRow11_2: EXACT AND COMPLETE MAILING ADDRESSK LG A_49: EXACT AND COMPLETE MAILING ADDRESSK LG A_50: EST YEARS OF DEBTRow11_2: DESCRIPTION OF DEBTRow11_2: MONTHLY PAYMENTRow11_2: ESTIMATED TOTAL OWEDRow11_2: NAME OF CREDITORRow12_2: EXACT AND COMPLETE MAILING ADDRESSK LG A_51: EXACT AND COMPLETE MAILING ADDRESSK LG A_52: EST YEARS OF DEBTRow12_2: DESCRIPTION OF DEBTRow12_2: MONTHLY PAYMENTRow12_2: ESTIMATED TOTAL OWEDRow12_2: NAME OF CREDITORRow13_2: EXACT AND COMPLETE MAILING ADDRESSK LG A_53: EXACT AND COMPLETE MAILING ADDRESSK LG A_54: EST YEARS OF DEBTRow13_2: DESCRIPTION OF DEBTRow13_2: MONTHLY PAYMENTRow13_2: ESTIMATED TOTAL OWEDRow13_2: NAME OF CREDITORRow14_2: EXACT AND COMPLETE MAILING ADDRESSK LG A_55: EXACT AND COMPLETE MAILING ADDRESSK LG A_56: EST YEARS OF DEBTRow14_2: DESCRIPTION OF DEBTRow14_2: MONTHLY PAYMENTRow14_2: ESTIMATED TOTAL OWEDRow14_2: NAME OF CREDITORRow1_3: EXACT AND COMPLETE MAILING ADDRESSK LG A_57: EXACT AND COMPLETE MAILING ADDRESSK LG A_58: EST YEARS OF DEBTRow1_3: DESCRIPTION OF DEBTRow1_3: MONTHLY PAYMENTRow1_3: ESTIMATED TOTAL OWEDRow1_3: NAME OF CREDITORRow2_3: EXACT AND COMPLETE MAILING ADDRESSK LG A_59: EXACT AND COMPLETE MAILING ADDRESSK LG A_60: EST YEARS OF DEBTRow2_3: DESCRIPTION OF DEBTRow2_3: MONTHLY PAYMENTRow2_3: ESTIMATED TOTAL OWEDRow2_3: NAME OF CREDITORRow3_3: EXACT AND COMPLETE MAILING ADDRESSK LG A_61: EXACT AND COMPLETE MAILING ADDRESSK LG A_62: EST YEARS OF DEBTRow3_3: DESCRIPTION OF DEBTRow3_3: MONTHLY PAYMENTRow3_3: ESTIMATED TOTAL OWEDRow3_3: NAME OF CREDITORRow4_3: EXACT AND COMPLETE MAILING ADDRESSK LG A_63: EXACT AND COMPLETE MAILING ADDRESSK LG A_64: EST YEARS OF DEBTRow4_3: DESCRIPTION OF DEBTRow4_3: MONTHLY PAYMENTRow4_3: ESTIMATED TOTAL OWEDRow4_3: NAME OF CREDITORRow5_3: EXACT AND COMPLETE MAILING ADDRESSK LG A_65: EXACT AND COMPLETE MAILING ADDRESSK LG A_66: EST YEARS OF DEBTRow5_3: DESCRIPTION OF DEBTRow5_3: MONTHLY PAYMENTRow5_3: ESTIMATED TOTAL OWEDRow5_3: NAME OF CREDITORRow6_3: EXACT AND COMPLETE MAILING ADDRESSK LG A_67: EXACT AND COMPLETE MAILING ADDRESSK LG A_68: EST YEARS OF DEBTRow6_3: DESCRIPTION OF DEBTRow6_3: MONTHLY PAYMENTRow6_3: ESTIMATED TOTAL OWEDRow6_3: NAME OF CREDITORRow7_3: EXACT AND COMPLETE MAILING ADDRESSK LG A_69: EXACT AND COMPLETE MAILING ADDRESSK LG A_70: EST YEARS OF DEBTRow7_3: DESCRIPTION OF DEBTRow7_3: MONTHLY PAYMENTRow7_3: ESTIMATED TOTAL OWEDRow7_3: NAME OF CREDITORRow8_3: EXACT AND COMPLETE MAILING ADDRESSK LG A_71: EXACT AND COMPLETE MAILING ADDRESSK LG A_72: EST YEARS OF DEBTRow8_3: DESCRIPTION OF DEBTRow8_3: MONTHLY PAYMENTRow8_3: ESTIMATED TOTAL OWEDRow8_3: NAME OF CREDITORRow9_3: EXACT AND COMPLETE MAILING ADDRESSK LG A_73: EXACT AND COMPLETE MAILING ADDRESSK LG A_74: EST YEARS OF DEBTRow9_3: DESCRIPTION OF DEBTRow9_3: MONTHLY PAYMENTRow9_3: ESTIMATED TOTAL OWEDRow9_3: NAME OF CREDITORRow10_3: EXACT AND COMPLETE MAILING ADDRESSK LG A_75: EXACT AND COMPLETE MAILING ADDRESSK LG A_76: EST YEARS OF DEBTRow10_3: DESCRIPTION OF DEBTRow10_3: MONTHLY PAYMENTRow10_3: ESTIMATED TOTAL OWEDRow10_3: NAME OF CREDITORRow11_3: EXACT AND COMPLETE MAILING ADDRESSK LG A_77: EXACT AND COMPLETE MAILING ADDRESSK LG A_78: EST YEARS OF DEBTRow11_3: DESCRIPTION OF DEBTRow11_3: MONTHLY PAYMENTRow11_3: ESTIMATED TOTAL OWEDRow11_3: NAME OF CREDITORRow12_3: EXACT AND COMPLETE MAILING ADDRESSK LG A_79: EXACT AND COMPLETE MAILING ADDRESSK LG A_80: EST YEARS OF DEBTRow12_3: DESCRIPTION OF DEBTRow12_3: MONTHLY PAYMENTRow12_3: ESTIMATED TOTAL OWEDRow12_3: NAME OF CREDITORRow13_3: EXACT AND COMPLETE MAILING ADDRESSK LG A_81: EXACT AND COMPLETE MAILING ADDRESSK LG A_82: EST YEARS OF DEBTRow13_3: DESCRIPTION OF DEBTRow13_3: MONTHLY PAYMENTRow13_3: ESTIMATED TOTAL OWEDRow13_3: NAME OF CREDITORRow14_3: EXACT AND COMPLETE MAILING ADDRESSK LG A_83: EXACT AND COMPLETE MAILING ADDRESSK LG A_84: EST YEARS OF DEBTRow14_3: DESCRIPTION OF DEBTRow14_3: MONTHLY PAYMENTRow14_3: ESTIMATED TOTAL OWEDRow14_3: Marital1: Off1:

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