Bankruptcy Evaluation Within One Day Evaluation Form Your Full Name* Phone number* E-mail address* Preferred method of contact* Via E-mail Via Phone Address (Optional) Have you filed bankruptcy before? no yes, more than 8 years ago yes, between 4 to 8 years ago yes, less than 4 years ago Debts Credit Card Debt none less than 2,500 2,500 - 10,000 10,000 - 25,000 25,000- 40,000 Personal Loans none less than 2,500 2,500 - 10,000 10,000- 25,000 Medical Bills none less than 2,500 2,500 - 10,000 10,000 - 25,000 Federal or State Income Taxes none less than 2,500 2,500 - 10,000 10,000 - 25,000 Student Loans none less than 2,500 2,500 - 10,000 10,000 - 25,000 Other Unsecured Debt none less than 2,500 2,500 - 10,000 10,000 - 25,000 Other Child support / Maintenance Judgments Garnishments Assets Your housing Rent Own home with mortgage Own home without mortgage Mobile home Are you behind in your mortgage or rent payments? Yes No Number of vehicles owned none 1 2 3 or more Current Income How many people live in your household? Are you single or married? Your monthly household income (gross) Other monthly household income Do you have unfiled income tax returns? Yes No Thank you! How did you hear about us? Google Newspaper Friend/Family Yelp Avvo Twitter Other Submit Please be advised that submission of this form does not create an attorney-client relationship.