Have you ever filed bankruptcy before?
Yes No
If so, in what year?
Year
Do you own a home or other real estate? Are you behind in your mortgage payments? If so, how many months are you behind?
Months
Do you own a mobile home? Do you receive bonuses at your work? Do you receive commissions or tips at your work?
Yes No
Do you own any cars, motorcycles, vans, RVs or other vehicles? If so, how many vehicles do you own outright?
Vehicles
If so, how many vehicles do you make payments on?
Vehicles
Have you filed all of your income tax returns for this year and the past 3 years? Do you owe the IRS any past due taxes? Do you owe any unpaid state taxes?
Yes No
Do you owe any unpaid property taxes? Do you owe on a student loan?
Yes No
Have you borrowed money from your IRA or other retirement plan to pay bills? Have you received any cash advances within the past 3 months? Do you have any loans with a credit union where you work? Are you leasing any buildings or equipment? Does an ex-spouse have a claim against you for any reason? Do you owe money on the purchase of jewelry, furniture or other household goods? Have you experienced, or do you expect to experience a foreclosure or repossession? Are you in the process of suing someone? Does anyone want to sue you or have they already filed a lawsuit against you? Does anyone have a claim against you due to a car accident?
Yes No
Have you used your credit cards to make purchases within the past 90 days? During the past 2 years,have you owned or had an interest in any business? Have you transferred any property with a retail value of $600 or more within the past 4 years? Have you stopped using all your credit cards? Do you have any credit cards you want to hold on to for an emergency? Are you behind in child support? Do you have any payday loans you still owe money for? Have you closed any bank accounts and left owing a balance? Do you have any bounced checks you owe additional fees for? Do you have any co-signers for your debts other than your spouse (if applicable)?
Yes No
Have you co-signed a loan for anyone other than your spouse (if applicable)? Are your wages currently being (or are soon to be) garnished? Do you have any judgments against you from any lawsuits that you lost? Do you have any lawsuits against you where the case is still pending? Do you have CDs, stocks, bonds or other types of financial accounts? Are you self-employed? If so, how long have you been self-employed?
Months
Are you currently drawing unemployment, retirement and/ or social security disability? Are you continuing to get new credit cards to cover essential living expenses? Are you borrowing money from friends/family to cover your debts? 
