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Secure Web FormPre-Meeting Bankruptcy Evaluation

This form is to be completed once you have scheduled your first meeting with out office.

Not yet scheduled?

Please click here to schedule a FREE CONSULTATION or call office at the telephone numbers above.

Please complete all the form below, fields marked with * are required to process.

PART A - Debtor's Contact Info
First Name*
Middle Name*
Last Name*
Sr./Jr.
E-mail*
Home Phone* (###-###-####)
Mobile Phone
Other Phone
Have you used any other names
in the last 8 years?
If YES, list other names:
County of Residence
  
Which Wiesneth office is your appointment scheduled with?*
(Please type; Evansville, Terre Haute, or Vincennes)
Address 1*
Address 2 (P.O. BOX)
City*
State*
Zip Code*
  
Have you lived at the above address
for at least 180 days?
Have you lived at the above address
for at least 730 days? (2 Years)
If you answered NO to either of the questions above, please list your previous address:

PART B - Marital Status
What is your Marital Status?
If Divorced, Date the divorce was final?

+ ADD SPOUSES INFO (If Married)

Spouse's Info
Spouse's First Name
Spouses Middle Name
Spouse's Last Name
Spouse's Social Security Number
Has your spouse used any other
names in the last 8 years?
If YES, list other names:
Address (If different from yours)
Address 2 (P.O. BOX)
City
State
Zip Code
  

PART C - Prior/Pending Bankruptcy Cases
Has a bankruptcy case ever been filed in your name (or your spouses name)?
If Yes, where was the prior claim filed?
Date Filed

PART D - Lawsuits
Are their currently any lawsuits against you?
If YES, please list the court case numbers:

PART E - Income

Your Employment Information
Place of Employment
How long at current employment?
Gross Wages Per Pay Period
How often are you paid?

Spouses Employment Information
Spouse's Place of Employment
Spouse's length at current employment?
Spouse's Gross Wages Per Pay Period
How often is your spouse paid?

+ ADD Additional Household Income

Additional Household Income

(Wages from someone else in the household)
Earner's Name
Relationship to you?
Place of Employment
Length at current employment?
Gross Wages Per Pay Period
How often are they paid?

+ ADD Other Income

Other Income
Are you or any member of your household receiving any disability, worker's compensation, social security, or other retirement income?
If YES, please list each such benefit:
Are you or any member of your household receiving government assistance (such as food stamps, day care vouchers, etc...)?
If YES, please list each such benefit:

PART F - Tax Returns
Have you filed all required tax returns (including any required business taxes) for the past three (3) years??
If NO, please explain why not:

Please list your reported incomes for each year below:
Debtor Income for 2010:
Spouse Income for 2010:
Debtor Income for 2009:
Spouse Income for 2009:
Are you currently expecting a tax refund check?
Did you receive a refund for tax year 2010?
If YES, approximately how much?
How much of the refund is left?
Have you ever filed your taxes late?
  
If YES, please state when and why:
Have you changed any payroll deductions within the past six months?

PART G - Dependants
Please list the gender and ages of each of your dependent children. (Please include all of your minor children who either live with you or for whom you pay support)
Please list any other person who is dependent on you or your spouse. (Please include their names, ages, and relationship to you.)

PART H - Financial Accounts
Do you have any financial accounts (checking, savings, CD, Christmas Club, etc)?
If YES, please list each such account. (ACCOUNT TYPE / BANK NAME / BALANCE):
Have you closed any financial accounts in the past 2 years? (These include checking, savings, retirement, IRA, stocks, mutual funds, Christmas Club)
If YES, please list each closed account:

PART I - Inheritances, Settlements, & Life Insurance
Have you received, or are you currently entitled to any inheritance, property settlement agreements, or proceeds from life insurance?
Are you expecting to receive any inheritance, property settlement agreements, or proceeds from life insurance within the next two (2) years?

PART J - Businesses and Partnerships
Do you have any ownership interest in a business or partnership?
If YES, please list the name(s) of the business(es):
Have you sold, transferred, or closed any business within the past three (3) years?
If YES, please list the name(s) of the business(es) and the date they were closed:

PART K - Recent Activity
Have you used credit cards in the past 3 months?
If YES, approximately how much debt have you put on the credit cards within the past three months?
Have you transferred any balances from one credit card to another credit card in the past three (3) months?
Have you taken any cash advances in the past three (3) months?
If YES, approximately how much have you taken out within the past three (3) months?

PART L - Domestic Relations
Do you owe or expect any money from a marital settlement or judgement of divorce?
Are you ordered to pay child support or spousal maintenance?
Do you owe any past due child support or spousal maintenance?
If YES, how much is past due?

PART L - Miscellaneous
Have you co-signed a loan for anyone else?
Is your name on anyone else's bank account, real estate, or vehicle?
Does anyone owe you money for any reason?
Do you have any claims against anyone or the right to sue anyone?
Have you set up a trust account in the past ten years?
Do you receive any income from a trust or annuity?
Do you receive any income from royalties, gas or mineral rights, copyrights, license agreements, or patents?
Do you own any stocks or bonds?
Do you have a safety deposit box?
If YES, what does it contain?
Do you have any secured debt (such as a mortgage or car loan) with the same financial institution where you have an unsecured debt (such as a personal loan or credit card)?
If YES, please list the name of the financial institution and the debts involved.

PART N - Real Estate

List all real estate you own or have any interest in (life estate, joint owner, etc.) Remember to include all real estate, even real estate that you still owe money on. (These include houses, condos, additional residence, rental properties, burial plots, undeveloped land, and farm land).

+ ADD Parcel

Parcel #1
Property Address:
List all owners:
List the current value of the real estate (from appraisal or tax assessment)
Are you behind in your monthly payments to this lender?
If YES, how far behind are you?
Does your monthly payment include property taxes and insurance?
If NO, how much do taxes and insurance cost you each month? (TAXES / INSURANCE)

+ ADD Parcel

Parcel #2
Property Address:
List all owners:
List the current value of the real estate (from appraisal or tax assessment)
Are you behind in your monthly payments to this lender?
If YES, how far behind are you?
Does your monthly payment include property taxes and insurance?
If NO, how much do taxes and insurance cost you each month? (TAXES / INSURANCE)

PART O - Vehicles
List all vehicles you own or have any interest in (joint owner, etc.)

+ ADD Vehicle

Vehicle #1
Year, Make, and Model of Vehicle
Name of Creditor
Current Value
Date Item was purchased
Total Loan Payoff
Monthly Payments
List All Owners
Are you behind on your monthly payments?
If YES, how far behind are you?
Do you want to keep this item?

+ ADD Vehicle

Vehicle #2
Year, Make, and Model of Vehicle
Name of Creditor
Current Value
Date Item was purchased
Total Loan Payoff
Monthly Payments
List All Owners
Are you behind on your monthly payments?
If YES, how far behind are you?
Do you want to keep this item?

PART P - Other Secured Debts

List all debts that are secured by collateral of any kind not already listed.  This includes a payment for any object that you own that, if you stop making the payment, the creditor could repossess the property.  Items in this category are things such as computers, furniture, televisions, vacuums, and the like.

+ ADD Secured Debt

Secured Debt #1
Description of Property
Name of Creditor
Current Value
Date Item was purchased
Total Loan Payoff
Monthly Payments
List All Owners
Are you behind on your monthly payments?
If YES, how far behind are you?
Do you want to keep this item?

+ ADD Secured Debt

Secured Debt #2
Description of Property
Name of Creditor
Current Value
Date Item was purchased
Total Loan Payoff
Monthly Payments
List All Owners
Are you behind on your monthly payments?
If YES, how far behind are you?
Do you want to keep this item?

PART Q - Other Debts

Please list total dollar amounts.
Tax Debts
Student Loans
Medical Bills
Credit Cards
Child Support Arrearages
Personal Loans
Check Advances
Past Due Utilities
Past Due Phone Bills
  
Has anything of yours ever been repossessed and you still owe an outstanding balance to the creditor?
If YES, please list the total amount of debt:
  
Do you have any debts other than those already listed?
If yes, please list:

By submitting this form you acknowledge that the contents of this form are provided by and are the responsibility of the person filling out and submitting the form. Your submission will NOT create an attorney-client relationship but will be treated as confidential.

*By checking this box I am indicating that I am the previously identified DEBTOR (Identified in PART A) and that the information provided to Wiesneth Law Offices, P.C. is true and accurate to the best of my knowledge.
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