Free Bankruptcy Consultation / Form

Please fill this form out to the best of your ability so that Mr. Brewer will be able to assess your financial situation.

This form is intended only for individuals seeking to file for bankrupty in Cleveland and Akron, Ohio and the surrounding areas.

---

General Information

Name	Spouse’s Name
Address	Home phone
City in Northern Ohio	Work phone
ZIP	eMail

Were you ever involved in any prior bankruptcy (Chapter 7 or Chapter 13)?

Yes No

Employment Information

What is your occupation? Name and address of current Employer. Name Address City State ZIP Pay Period select one every week every other week 15th and end of month once per month How long have you been at your current job? select one 1 year or less 2 years 3 years 4 years 5 - 10 years 10 years or more If you have been at your current job less than one (1) year, describe your previous position. What is the amount of your monthly take home after taxes?

What is your spouse’s occupation? Name and address of current Employer. Name Address City State ZIP Pay Period select one every week every other week 15th and end of month once per month How long have they been at their current job? select one 1 year or less 2 years 3 years 4 years 5 - 10 years 10 years or more If your spouse has been at their current job less than one (1) year, describe their previous position and length they were employed. What is the amount of your spouse’s monthly take home after taxes?

Current Debt

Please provide estimates of your debt for each of the below categories.  You will be asked to provide more specific information after your initial consultation;  therefore, it is understood that the figures you provide today may change prior to completing your legal documents.

Credit Card Debt
Medical Bills
Repossession Debt
Wage Garnishments
Personal Loans
Student Loans
Other

Your Residence

If you RENT, please provide your monthly rent payment?

If you own your home and it is encumbered by a mortgage(s), please provide the following information:

1st Mortgage

Balance
Payment
Arrearage (Amount you owe for back payments.)
Name of Mortgage Company

 

2nd Mortgage

Balance
Payment
Arrearage (Amount you owe for back payments.)
Name of Mortgage Company

What is the estimated value of your home?

To find out what homes have recently sold for in your neighborhood go to www.bankofamerica.com

Have you had your home appraised?

Yes No

If YES, provide date:  month Jan Feb Mar Apr May Jun Jul Aug Sep Oct Nov Dec  / year 2005 2004 2003 2002 2001 2000

Your Family

List the sex and ages of all children whom you declare as dependents on your taxes:

1st dependent	m/f male female	age 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18
2nd dependent	m/f male female	age 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18
3rd dependent	m/f male female	age 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18
4th dependent	m/f male female	age 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18
5th dependent	m/f male female	age 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18

Your Vehicles

Do you have a vehicle(s)? If YES, complete the following:

	1st Vehicle	2nd Vehicle
Type of vehicle vehicle
Year
Make
Model
Mileage
Check if paid in full.
I am financing the purchase of my car.
Monthly payment
Past due amount
Balance (pay off)
I am leasing my vehicle.
Monthly payment
Past due amount

Thank you very much for completing this information.

Mr. Brewer will not divulge any information submitted here to any third party for any reason.