Before your first visit, please complete and print the following questionnaire.

Remember to bring your Drivers License and Social Security Card with you.

Thank you.

 

TODAY'S DATE

Name

Social Sec. No.

Spouse

Social Sec. No.

Address

City , State , Zip

County

Home Phone Cell Phone

E-mail Address

How long have you lived in this state?

Dependents? (Name & Age)

How did you find out about our firm?

PERSONAL INFORMATION

Occupation (You) (Spouse)

Work Phone No. (You) How Long?

Work Phone No. (Spouse) How Long?

Date of Birth

Marital Status: Married Single Separated Divorced

Name of Employer (You)

Name of Employer (Spouse)

Do you: Rent Own

Have you ever filed for bankruptcy or debt consolidation? yes no

What year?

Are you behind in house or rent payments? yes no

How many payments?

Do you owe taxes? yes no
   How much? IRS? State? County?

Are you expecting an income tax refund this Spring? yes no

How much?

Do you owe student loans? yes no

How many? How much?

Are you behind in child support or spousal support? yes no

How much?

Do you have any outstanding NSF (non-sufficient funds) checks? yes no

How much? Are any of the checks with check advance companies? yes no

NSF checks to a grocery store, department store or somebody else in exchange for goods and services must be taken care of by yourself.


SECURED DEBTS:

HOME LOANS:

1st MTG Pymnt $ /mo. Loan Total $ Behind? yes no

How many?
2nd MTG Pymnt $ /mo. Loan Total $ Behind? yes no

How many?
3rd MTG Pymnt $ /mo. Loan Total $ Behind? yes no

How many?

What is the value of your home?
What year did you purchase your home?
Purchase Price?

Do you own or have any ownership interest in any other Real Estate? yes no
Approximate value of property $
Year purchased Purchase price $

VEHICLES: Please list the year, make and model of ALL vehicles in your name or possession

1st Auto(yr,make,model):
Paid For Buying Leasing Title Loan
Mo. Pmnt. Balance

2nd Auto(yr,make,model):
Paid For Buying Leasing Title Loan
Mo. Pmnt. Balance

3rd Auto(yr,make,model):
Paid For Buying Leasing Title Loan
Mo. Pmnt. Balance

Are you behind on any car payments? Yes No How many?
Date of most recent purchase

PLEASE LIST ALL OF YOUR CREDITORS - It is very important that you list ALL of your creditors.

If any of your debts have cosigners, codebtors, or somebody else may be liable for the debt, please let us know by placing a star (*) next to the name of the cosigned creditor and write down the co-signer's name.

..........Monthly Payment............... Total Amount............#Payments
..........Company.........Amount...........Owed (Balance)..........Behind

1.

2.

3.

4.

5.

6.

7.

8.

9.

10.

11.

12.

13.

14.

15.

16.

17.

18.

19.

20.

Are your wages now being garnished or about to be garnished?
yes no

Give details:

Do you have any outstanding judgments against you?.... yes no

Who?

Do you have any pending lawsuits against you? ...... yes no

Who?



APPROXIMATE INCOME & EXPENSES

Income:

Estimated Future Monthly Living Expenses:

Rent/Mortgage/Homeowners Assn./Space Rent Payment $

Utilities: Elec.& Gas Water Phone Cable $

Food $

Clothing $

Home Maintenance (including cleaning products) $

Laundry & Cleaning $

Newspapers, Magazines, Books (Including School Books) $

Medical, Dental & Medicines (excluding health insurance) $

Auto Insurance (per month) $

Other Insurance (not deducted from your paycheck) $

Auto operating costs - gas, oil & maintenance $

Child or Spousal Support $

Day Care $

1st Auto Payment $

2nd Auto Payment $

Other installment payments (specify) $

 

Other living expenses (specify) $

 

TOTAL MONTHLY EXPENSES: $



Have you listed all credit cards? yes no

Any cash advances in the last 12 months? yes no

Any gambling losses (casinos, bingo, sporting events)? yes no

Have you listed all furniture loans? yes no

Have you listed all outstanding medical bills? yes no

Are you current on utilities (phone, power, cable)? yes no

Have you cosigned a loan for anybody or are there any debts for which you have a cosigner? yes no

Do you have rent-to-own contracts, pawns, or check advance loans? yes no

Do you have any 401K, IRA, thrift-savings, or retirement plan loans? yes no

Have you transferred or sold any property recently? yes no