Financial Questionnaires

CONFIDENTIAL FINANCIAL QUESTIONNAIRE

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- Step 1 of 5

Basic Information of Person 1

Name *

First

Last

Email Address *

Phone Number

How Long in Nevada?

Prior Bankruptcy?

Address

Address Line 1

Address Line 2

City

State

Zip Code

Would you like to add the 2nd person's information as Person 2? *

Basic Information of Person 2

Person 2 Name *

First

Last

Child Retirement Layout

Person 2 Email Address *

Person 2 Phone Number

How Long in Nevada? (person 2)

Prior Bankruptcy? (Person 2)

Person 2 Address

Address Line 1

Address Line 2

City

State

Zip Code

Income information of Person 1

Please enter the name of the employer

Wages

Gross Amount

(before tax & insurance)

Take Home

(after tax and insurance)

Frequency

Please check the other Sources of $ received.

Disability
Unemployment
Social Security
Child Support
Alimony
Rental/Roommate Income
Investment Income
Student Loans
Retirement Income
Gambling Income

Disability

Gross Amount

(before tax & insurance)

Take Home

(after tax and insurance)

Frequency

Unemployment

Gross Amount

(before tax & insurance)

Take Home

(after tax and insurance)

Frequency

Social Security

Gross Amount

(before tax & insurance)

Take Home

(after tax and insurance)

Frequency

Child Support

Gross Amount

(before tax & insurance)

Take Home

(after tax and insurance)

Frequency

Alimony

Gross Amount

(before tax & insurance)

Take Home

(after tax and insurance)

Frequency

Rental/Roommate Income

Gross Amount

(before tax & insurance)

Take Home

(after tax and insurance)

Frequency

Investment Income

Gross Amount

(before tax & insurance)

Take Home

(after tax and insurance)

Frequency

Student Loan Income

Gross Amount

(before tax & insurance)

Take Home

(after tax and insurance)

Frequency

Retirement Income

Gross Amount

(before tax & insurance)

Take Home

(after tax and insurance)

Frequency

Gambling Income

Gross Amount

(before tax & insurance)

Take Home

(after tax and insurance)

Frequency

Income information of Person 2

Please enter the name of the employer for person 2

Wages (person 2)

Gross Amount

(before tax & insurance)

Take Home

(after tax and insurance)

Frequency

Please check the other Sources of $ received. (For person 2)

Disability
Unemployment
Social Security
Child Support
Alimony
Rental/Roommate Income
Investment Income
Student Loans
Retirement Income
Gambling Income

Disability (person 2)

Gross Amount

(before tax & insurance)

Take Home

(after tax and insurance)

Frequency

Unemployment (person 2)

Gross Amount

(before tax & insurance)

Take Home

(after tax and insurance)

Frequency

Social Security (person 2)

Gross Amount

(before tax & insurance)

Take Home

(after tax and insurance)

Frequency

Child Support (person 2)

Gross Amount

(before tax & insurance)

Take Home

(after tax and insurance)

Frequency

Alimony (person 2)

Gross Amount

(before tax & insurance)

Take Home

(after tax and insurance)

Frequency

Rental/Roommate (person 2)

Gross Amount

(before tax & insurance)

Take Home

(after tax and insurance)

Frequency

Investment Income (person 2)

Gross Amount

(before tax & insurance)

Take Home

(after tax and insurance)

Frequency

Student Loan Income (person 2)

Gross Amount

(before tax & insurance)

Take Home

(after tax and insurance)

Frequency

Retirement Income (person 2)

Gross Amount

(before tax & insurance)

Take Home

(after tax and insurance)

Frequency

Gambling Income (person 2)

Gross Amount

(before tax & insurance)

Take Home

(after tax and insurance)

Frequency

Secured Debts You are Paying

Home Mortgage

Balance

Monthly Payment Amount

Second Mortgage

Balance

Monthly Payment Amount

Other Mortgage or Liens on Home

Balance

Monthly Payment Amount

Solar or Home Repair/Maintenance expense

Balance

Monthly Payment Amount

Vehicle Loan 1

Balance

Monthly Payment Amount

Vehicle Loan 2

Balance

Monthly Payment Amount

Other Vehicle Loan or Vehicle Toys such as RV, ATV, boat, trailer.

Balance

Monthly Payment Amount

Tax Lien

Balance

Monthly Payment Amount

Judgment Lien

Balance

Monthly Payment Amount

Other Expenses Unsecured Debt

Tax Debt

Estimated Balance

Monthly Payment Amount

Student Loans

Estimated Balance

Monthly Payment Amount

Other Loans

Estimated Balance

Monthly Payment Amount

Credit Cards

Estimated Balance

Monthly Payment Amount

Medical Debt

Estimated Balance

Monthly Payment Amount

Other debts

Personal Loan(s)

Estimated Balance

Monthly Payment Amount

Business Loan(s)

Estimated Balance

Monthly Payment Amount

Business Debt(s) Guaranteed

Estimated Balance

Monthly Payment Amount

Lawsuit(s)

Estimated Balance

Monthly Payment Amount

Accident Claim against you

Estimated Balance

Monthly Payment Amount

Marital Status

Married and Living together
Married and Living apart
Divorced
Single
Never Married

Anyone living with you if you pay some or all of their expenses.

Name

Age

Relation

Name (2)

Age (2)

Relation (2)

Name (3)

Age (3)

Relation (3)

Name (4)

Age (4)

Relation (4)

Monthly Living Expenses

Expenses Estimate your average monthly living expenses. If your expenses this month are unusually high or low, put down a typical amount. If you & your spouse are separated, s/he should complete a separate copy of this page. If you have other expenses not on this form, put them down too!

4. Rent or 1st mortgage

4A. Property taxes

4B. Rental/Home Ins

4C. Home repairs, upkeep

4D. HOA

5. 2nd or 3rd Mortgage

6A. Power & natural gas

6B. Trash, Water & sewer

6C. Phone, cell, internet, cable

6D. Other utilities: (Describe)

7. Food/Groceries & HH exp

8. Childcare, Edu School Exp

9. Clothes, laundry, dry cleaning

10. Personal care products & services

11. Medical & dental expenses

12. Gas, oil, repairs (exc loan pmts)

13. Rec & entertainment

14. Charitable contributions

15A. Life Insurance (not from pay)

15B. Health insurance (not from pay)

15C. Vehicle Insurance

15D. Other insurance

16. Taxes (not from wages)

17A. Vehicle payment 1

17B. Vehicle payment 2

17C. Other installment Describe

18. Student loans

19 Alimony/Child you pay

20. Support to dependents

21. Other real estate expenses

22. Other real estate expenses

23. Bank service charges

24. Storage Unit

25. Pet care

26. Cigarettes/Tobacco

27. Non-food purchases

28. Security System

29. Lunch at work

30. Other un-reimbursed wk expenses

31. Other expenses: Describe

31B. Other expenses: Describe

31C. Other expenses: Describe

Basic Information of Person 1

Basic Information of Person 2

Income information of Person 1

Income information of Person 2

Secured Debts You are Paying

Other Expenses Unsecured Debt

Other debts

Anyone living with you if you pay some or all of their expenses.

Monthly Living Expenses

Expenses Estimate your average monthly living expenses. If your expenses this month are unusually high or low, put down a typical amount. If you & your spouse are separated, s/he should complete a separate copy of this page. If you have other expenses not on this form, put them down too!

Dorothy Bunce, our attorney, is actively licensed with the US District Court of Nevada, which covers the Bankruptcy Court, as well as the State Bar of Nevada. She is also an active member of the Southern Nevada Association of Bankruptcy Attorneys as well as several other professional organizations.

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