Bankruptcy Initial Evaluation Please enable JavaScript in your browser to complete this form.Please enable JavaScript in your browser to complete this form.Communication with a lawyer through this form does not create an attorney-client relationship and any information submitted will not be confidential or privileged. No information disclosed will prohibit the lawyer from representing a different client in the matter. Do not disclose any information that you would not want released to a third-party. If you do not agree to these terms, please close your browser and do not fill out any of the fields. *I agreePlease take about 30 minutes and fill out the requested information. Be as complete as you can. If you do not know the exact answer, use your best guess. Please be as complete as possible. If you do not know some answers, there is an option at the end to save the form and resume later.Name *FirstLastPhone *Email *Address where you live - do not use P.O. Box *Address Line 1Address Line 2City--- Select state ---AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingStateZip CodeHave you lived in North Carolina for the past three years? *YesNoList all the states you have lived in the past three years and the dates you lived thereAre you looking to file bankruptcy by yourself or with a spouse? *I'm not marriedJust me, but not my spouseMe and my spouseI'm married, but I'm not sure if my spouse needs to file tooWhy are you considering bankruptcy? Check all the apply. *Too much unsecured debt (credit cards, personal loans, medical debts)Facing foreclosureFacing auto repossessionOwe back taxesBeing sued for a debtLate on rentStudent loansHow many people live in your home at least 50% of the time? *Include spouse, children, and any other relatives or significant others. Do not include roommates.Is there anyone that lives in your home some of the time, but not every day of the week?YesNoThis could be a college-aged child home for a summer, or a child that only lives with you some of the time. Sources of Income: Do you or a spouse receive any of the following? Check all that apply. *Wages from an employerSelf-employed incomeSocial Security Retirement or DisabilityMilitary or VA DisabilityOther retirement or pensionAlimony or child supportRegular government assistanceNone of the above List monthly income for you and your spouse Do you work for an employer? *YesNoNot currently, but I have worked in the past six-months.None of the aboveHow often are you paid? *WeeklyEvery two weeks (26 times a year)Twice per month (24 times a year)MonthlyOther - I will convert my yearly income to monthly incomeGross pay - average paycheck amount BEFORE any deductions *Net pay - average paycheck amount AFTER all deductions *Does your spouse work for an employer? *YesNo/not marriedNot currently, but has worked in the past six-months.How often is your spouse paid? *WeeklyEvery two weeks (26 times a year)Twice per month (24 times a year)MonthlyOther - I will convert my yearly income to monthly incomeSpouse's gross pay - average paycheck amount BEFORE any deductions *Spouse's net pay - average paycheck amount AFTER all deductions *Household net employment income (calculated) List self employed income for you and your spouse Do you have self-employed income *YesNoNot currently, but I have in the past yearAverage self-employed revenue before expenses *Business expenses - do not include personal expenses *Net monthly self-employment income (calculated) *Does your spouse have self-employed income *YesNo/not marriedNot currently, but has in the past yearSpouse's average monthly revenue before expenses *Spouse's business expenses - do not include personal expenses *Spouse's net monthly self-employment income (calculated) *Household self-employment Income (calculated) * Household income other than from employment List income for you and your spouse.Social Security Payments *Military of VA Disability Payments *Other retirement income *Alimony or child support received *Regular government assistance *Does anyone other than your spouse or help pay monthly household expenses, either directly paid to you or paid on your behalf *YesYes - from roommate who is not a relative or significant otherNoNot currently, but I have in the six monthsFor an average month, how much monetary help do you recieve *Total Social Security & Military/VA disability income (calculated)Total other income (calculated) Monthly Expenses: Instructions for filling out monthly expenses: Below you will fill out the expenses for your household. Usually, this will mean expenses for you, your spouse, and any children living in the house. If you have a roommate and you share expenses, only list the expenses you pay. If you are supporting another family member in your house, only list the expenses that you pay directly. For example, if your mother has Social Security income and lives with you and she pays for all of her own prescriptions, do not list that. If you buy her grocieries, do include that in your grocery total. If you have a mortgage with escrowed taxes and insurance (the mortgage company pays those expenses), do not list expenses for taxes and insurance. Do not list expenses deducted from your paycheck (for example - health insurance, retirement contributions, taxes, child support). For your utilities, use an average amount for the year. Do not use the high amount you pay in winter or summer months. If you have propane or heating oil expenses, divide your yearly total by 12. You will not enter amounts for unsecured debts. We will address that separately. If you have expenses that you think we should know about but don't fit in the prepopulated box, there is a separate box to type any explanation. If understand the instructions above *I understand Home Mortgage/RentHome/Renters InsuranceHOA/Condo FeesRepairs/UpkeepProperty TaxesHome expense total Utilities ElectricWater/Sewer/TrashInternet/TV/Streaming Services/Landline PhoneGas/Propane/Heating Oil (monthly average for the year)Cell PhoneOther UtilityUtilities total Personal Expenses GroceriesHair CutsClothing/LaundryEating OutPersonal Care ProductsRecreationPersonal expense total Medical/Medical Insurance Medical Copays Not Covered By HSAMonthly Vision ExpensesSelf-Pay Health InsuranceMedical total Taxes/Life Insurance Tax Payments This is not what you pay on back taxes. If you always owe at the end of the year, enter 1/12 of that amount. If you pay quarterly taxes, enter a monthly amount.Self-Pay Life InsuranceSelf-Pay Other InsuranceOther Self-Pay InsuranceFor example: disability or long-term care insuranceTaxes total Vehicles Auto Payment 1Lease or loan paymentsGasAuto InsuranceAuto Payments 2Lease or loan paymentsOil Changes/MaintenanceOther Transportation ExpensesParking/Rideshare/Bus feesOther PaymentsRV's, trailers, ATV'sVehicle totals Family/Other Daycare/BabysitterEducation/Professional Expenses for Worklicense fees, continuing education fees, professional insuranceCharity/TithesChildren's Education ExpensesContributions to other family membersFamily total Other Income & Expenses - Additional Information List any other income or expenses below or provide any information you would like us to know about your budget above. Income & Expense Summary (calculated): Gross Yearly Household Income - Less Social Security & VA DisabilityHousehold SizeHousehold Net Income - All SourcesNet Household ExpensesNet Household BudgetWhat do you estimate is the total amount of unsecured debt you have, other than student loans? *Unsecured debt could be credit card debt, medical debt, personal loans, deficiency balance on a vehicle repossession, etc.If you have student loans, what is the balance?What do you estimate is the total amount of unsecured debt you and your spouse have, other than student loans? *Unsecured debt could be credit card debt, medical debt, personal loans, deficiency balance on a vehicle repossession, etc.If you have student laons, what is the balance?Do you own or have a mortgage on your home? *I own my home with no mortgageI have a mortgage on my homeI do not own my homeType of property: *Conventional home built on a foundationCondominium or town-homeModular homeDouble-wide mobile homeSingle-wide mobile homeDo you own the land? *I own the land tooI pay lot rentI don't own the land or pay lot rentEstimated Home ValueDo not use tax value. What would be a fair price if someone offered to buy it?Estimated Mortgage BalanceAbout how much do you owe on your mortgage?Are you current on your mortgage payments? *YesNoWhat is the total dollar amount of missed mortgage payments? *Are you trying to keep your home from being foreclosed? *YesNoDo you own any vehicles or make payments on a vehicle other than a lease? *YesNoThis could be a vehicle that you have with a loan, or a vehicle without a loan, including buy-here-pay-here loans. Include automobiles, motorcycles, atv's, and trailers.How many vehicles do you own *1234More than 4Include automobiles, motorcycles, atv's, and trailers. If your name is not on the title, you do not need to list that vehicle.What is the year, make, model, trim, and approximate mileage of your vehicle *For example: 2010 Ford F-150 XLT 4x4 crew cab, 150,000 milesIs there a loan on the vehicle? *YesNoWhat is the loan balance? *What is the year, make, model, trim, and approximate mileage of your second vehicle? *For example: 2010 Ford F-150 XLT 4x4 crew cab, 150,000 milesIs there a loan on the second vehicle? *YesNoWhat is the loan balance on your second vehicle? *Please list any additional vehicles any loan balancesIn the past year, have you repaid any debts to friends or family that totaled over $750?YesNoIn the past year, have you had any reposessions, foreclosures, or garnishments?YesNoIn the past two years, have you given any gifts worth over $600 to any one person? YesNoHave you sold any property within the past two years? This could include a home or a car.YesNoHow do you intend to pay for your bankruptcy? Check all that apply.SavingsMonthly paymentsHelp from friends or familyGet a second jobAnticipated tax refundSell some personal belongingsSubmitSave and Resume Later Your form entry has been saved and a unique link has been created which you can access to resume this form. Enter your email address to receive the link via email. Alternatively, you can copy and save the link below. Please note, this link should not be shared and will expire in 30 days, afterwards your form entry will be deleted. Copy Link Email * Send Link
