Do you own real estate that is worth less than you owe?

Yes
No

Are you late in payments on any real estate?

Yes
No

If you have been notified of a foreclosure what is the sale/auction date?

Are you late in car payments?

Yes
No

Is the car too expensive?

Yes
No

Are there any wage garnishments or repossessions?

Yes
No

If yes, please explain:

Have you recently been sued?

Yes
No

What are your last six months of GROSS INCOME (before taxes and other deductions)?

Have you filed bankruptcy in the past?

Yes
No

Feel free to write as much as you want explaining anything you feel important to your situation/circumstance:

* First Name:

* Last Name:

* E-Mail:

* Phone Number: