Page Number (required) 1    2    3    4    5    6

Client Information:

What is your full name?

What is your spouse's full name?

Debt 1

1. Creditor Name

2. Street Address     PO Box

  City       State       Zip Code

3. Account #

4. Is this debt secured by a mortgage, lien, or other security interest on any property?    Yes    No

5. Which spouse is liable for this debt?    Husband    Wife    Both

6. Is anyone else liable for the debt?    Yes    No

7. If so, list the name and address below.

   

8. When did you open this account?    Month Unsure January February March April May June July August September October November December    Year Unsure 2010 2009 2008 2007 2006 2005 2004 2003 2002 2001 2000 1999 1998 1997 1996 1995 1994 1993 1992 1991 1990 1989 1988 1987 1986 1985 1984 1982 1981 1980 prior

9. What did you purchase with this debt?    Nothing
   

10. What is the total amount of this debt? $

11. Do you wish to re-affirm (i.e., remain liable for after bankruptcy) all or any part of this debt?
    Yes    No

Additional information about Debt 1

DEBT 2

1. Creditor Name

2. Street Address     PO Box

  City       State       Zip Code

3. Account #

4. Is this debt secured by a mortgage, lien, or other security interest on any property?    Yes    No

5. Which spouse is liable for this debt?    Husband    Wife    Both

6. Is anyone else liable for the debt?    Yes    No

7. If so, list the name and address below.

   

8. When did you open this account?    Month Unsure January February March April May June July August September October November December    Year Unsure 2010 2009 2008 2007 2006 2005 2004 2003 2002 2001 2000 1999 1998 1997 1996 1995 1994 1993 1992 1991 1990 1989 1988 1987 1986 1985 1984 1982 1981 1980 prior

9. What did you purchase with this debt?    Nothing
   

10. What is the total amount of this debt? $

11. Do you wish to re-affirm (i.e., remain liable for after bankruptcy) all or any part of this debt?
    Yes    No

Additional information about Debt 2

DEBT 3

1. Creditor Name

2. Street Address     PO Box

  City       State       Zip Code

3. Account #

4. Is this debt secured by a mortgage, lien, or other security interest on any property?    Yes    No

5. Which spouse is liable for this debt?    Husband    Wife    Both

6. Is anyone else liable for the debt?    Yes    No

7. If so, list the name and address below.

   

8. When did you open this account?    Month Unsure January February March April May June July August September October November December    Year Unsure 2010 2009 2008 2007 2006 2005 2004 2003 2002 2001 2000 1999 1998 1997 1996 1995 1994 1993 1992 1991 1990 1989 1988 1987 1986 1985 1984 1982 1981 1980 prior

9. What did you purchase with this debt?    Nothing
   

10. What is the total amount of this debt? $

11. Do you wish to re-affirm (i.e., remain liable for after bankruptcy) all or any part of this debt?
    Yes    No

Additional information about Debt 3.

Debt 4

1. Creditor Name

2. Street Address     PO Box

  City       State       Zip Code

3. Account #

4. Is this debt secured by a mortgage, lien, or other security interest on any property?    Yes    No

5. Which spouse is liable for this debt?    Husband    Wife    Both

6. Is anyone else liable for the debt?    Yes    No

7. If so, list the name and address below.

   

8. When did you open this account?    Month Unsure January February March April May June July August September October November December    Year Unsure 2010 2009 2008 2007 2006 2005 2004 2003 2002 2001 2000 1999 1998 1997 1996 1995 1994 1993 1992 1991 1990 1989 1988 1987 1986 1985 1984 1982 1981 1980 prior

9. What did you purchase with this debt?    Nothing
   

10. What is the total amount of this debt? $

11. Do you wish to re-affirm (i.e., remain liable for after bankruptcy) all or any part of this debt?
    Yes    No

Additional information about Debt 4