Form

Request Type*

I already have an appointment Please contact me to set up an appointment I will call 480-802-4647 to set an appointment
Your Name*
First Name Last Name
Your Spouse's Name
First Name Last Name
E-mail*
Address*
City*
State*
Zip*
Primary Phone*
- Area Code Phone Number
Alternate Phone
- Area Code Phone Number
Best Time to Contact
How did you find us?
....
Real Property
Current Home Value
1st Mortgage - Total Payoff Amount
1st Mortgage - Monthly Payment
1st Mortgage - Delinquency Amount
2nd Mortgage - Total Payoff Amount
2nd Mortgage - Monthly Payment
2nd Mortgage - Delinquency Amount
Do you have a second home, vacation home, or land that you want to keep?

Yes No
Vehicles
Auto #1 - Year/Make/Model/Miles
Auto #1 - Lender
Auto #1 - Value (use kbb.com -> private seller value)
Auto #1 - Loan Payoff Amount
Auto #1 - Monthly Payment
Auto #1 - Delinquency Amount
Auto #2 - Year/Make/Model/Miles
Auto #2 - Lender
Auto #2 - Value (use kbb.com -> private seller value)
Auto #2 - Loan Payoff Amount
Auto #2 - Monthly Payment
Auto #2 - Delinquency Amount
More than two automobiles?

Yes No
Do you have a boat, RV, ATV, or PWC?

Yes No
Taxes
Total Tax Debt
Tax Years Owed
Other Debts and Expenses
Total Credit Card Debt*
Total Medical Debt
List Any Other Debts with Amount Owed
Income and Household
Which type of Bankruptcy will you file?*

Individually Jointly w/ Spouse Married (But filing Individually)
Household Size*
Gross Income - Include your spouse if married (even if filing individually)
Last Month Gross*
2 Months Ago Gross*
3 Months Ago Gross*
4 Months Ago Gross*
5 Months Ago Gross*
6 Months Ago Gross*
Previous Bankruptcy
Have you filed Bankruptcy before?*

Yes No
What Year
What Chapter?

Chapter 7 Chapter 11 Chapter 13
Business
Have you owned a business in the last 2 years?*

Yes No
Entity Type(s) of Business

Sole Proprietorship Partnership LLC S Corp C Corp
Do you have business debt that is personally guaranteed?

Yes No Don't Know
Miscellaneous
Do you have a wage garnishment, foreclosure, repossession, lien, or other legal action that you need to stop?*

Yes No
If Yes, Give Details Here
How Long Have You Lived in Arizona*
When do you hope to file for bankruptcy
- Month - Day Year
Comments, notes, or explanations for any of the above questions
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Should be Empty:

Real Property

Vehicles

Taxes

Other Debts and Expenses

Income and Household

Previous Bankruptcy

Business

Miscellaneous