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Free Online Bankruptcy Evaluation Form

Please answer as many of the following questions as you can.


Full Name
Address
Phone
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Email Address

Best time to contact you?
What type of bills do you have?
(Check all that apply)






Number of bills
Amount Owed:






Approximate value of home:
Approximate balance on mortgage:
Monthly mortgage payment:
Are you up to date on your mortage payments?
Are there any other mortgages on this property?
Vehicle 1
Year/Make/Model:
Approximate Value:
Approximate Balance:
Monthly Payment:
Are your payments up to date?
Vehicle 2
Year/Make/Model:
Approximate Value:
Approximate Balance:
Monthly Payment:
Are your payments up to date?
Enter any other property of significant value. (For example, if you own a boat, list it here.)
You
Are you employed?

How often do you get paid?


Net Pay:
(after taxes, medical adn other deductions)
What other types of income do you have?
(Check all that apply)







Spouse (optional)
How often do you get paid?



Net Pay:
(after taxes, medical and other deductions)
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We are a qualified debt relief agency. This is Attorney Advertising. The information on this website is for general information purposes only. Nothing on this or associated pages, documents, comments, answers, emails, or other communications should be taken as legal advice for any individual case or situation. This information on this website is not intended to create, and receipt or viewing of this information does not constitute, an attorney-client relationship.

Address: 1737 N. Ocean Ave | Medford, Long Island | New York | Telephone: (888) 229-0413