Bankruptcy Evaluation Form :: LeadRival

Why are you Considering Bankruptcy? (check all that apply)

Garnishment
Repossession
Foreclosure
Lawsuit

Illness / Disability
Divorce
Job Loss
Other:

Go to Step 2 of 5 >>

Please Estimate Your Total Unsecured Debt

(Do Not Include your Mortgage, Auto Loans or Student Loans)

Total Debt =

Go to Step 3 of 5 >>

Do you Own a Home?

Yes No

Monthly Mortgage: $
Approximate Mortgage Balance: $
Approximate Value of Home: $
Are Your Payments Current? Yes No

Do you Have Any Other Important Assets? If so Please Describe:

Go to Step 4 of 5 >>

What is YOUR Net Monthly Income:

$

What is your SPOUSE'S Net Monthly Income:

$

Go to Last Step >>

First Name:

Last Name:

Street Address:

Zip Code:

Email:

Phone Number:

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