Other Names Used In The Past 8 Years:   

SSN:     Date of Birth:      Marital Status:  Please Select Married Single Divorced Widow Separated

Street Address:   

City:      State:      Zip:     County:  

Client Mailing Address:   

Mailing City:        Mailing State:     Mailing Zip: 

Have you moved to Georgia in the last 2 years?   Yes        If so, when?   

Have you filed bankruptcy before?    Yes

If yes, when?        Where?   

Case No(s)        Type:    Please Select Chapter 7 Chapter 13

Are any of the cases listed above still open?    Yes

Client Phone:                  Client Cell/Pager:       

Client Work Phone:        Email: 

Employment Information:

Client Employer Name:    

Client Payroll Address: 

Payroll City:        Payroll State:       Payroll Zip:   

How Long At This Job?:        Job Title:   

Do you regularly receive paystubs or other evidence of your wages from your employer?     Please Select Yes No N/A

How often do you get paid?    Please Select Weekly Bi-Weekly Semi-Monthly Monthly

GROSS INCOME   (before deductions) per pay period (including over time pay):   

Take home (after deductions) per pay period:   

Check any deductions from your pay:

401(k)   Retirement Plan   Child Support   Union Dues    Uniforms   
Additional Deductions

Other Income:       Source(s) of other income:   

What was your total GROSS INCOME from all sources during the past six (6) months?:   

What was your SPOUSE's total GROSS INCOME from all sources during the past six (6) months?:   

                           Total income                                Total income                              Total income
                                this year                                       last year                             year before last

(Self)                                         

(Spouse)                                   

What was the last year that you filed a tax return?:   

What state did you live in when you filed it?:   

The last year you were required to file a return?:   

Did you file all tax returns for the past 4 years?:    Please Select Yes No

Do you own any interest in an education individual retirement account or a qualified state tuition program?:    Please Select Yes No

Dependents Relationships and Ages:

1.    Relation:    Age:          2.   Relation:      Age:   

3.    Relation:    Age:          4.   Relation:      Age:   

5.    Relation:    Age:          6.   Relation:      Age:   

Other than above, does anyone else live with you?:   

Do you contribute to the support of anyone else??:    Please Select Yes No

If so, explain.:   

How did you hear about us?

Please Select Mail advertisement - Foreclosure Mail advertisement - Garnishment Mail advertisement - Lawsuit Highway Sign Referral Daily Report Newspaper Previous Client TV/Radio Website Yellow Pages     Other, please specify:   

Spouse Information:

If you are married (even if your spouse is not filing),  please complete the spouse's information below:

First Name:      Middle Name:        Last Name:   

Please list any other name(s) you are known by:   

Social Security #:            Date of Birth:   

Street Address:   

City:        State:        Zip:   

Mailing Address:   

Mailing City:        Mailing State:        Mailing Zip:   

Did you move to Georgia in the last 2 years?:    Please Select Yes No

Have you ever filed for bankruptcy?:    Please Select Yes No

Home Phone:        Cell/Pager:   

Work Phone:        Email Address:   

Employer:   

Payroll Address:   

Payroll City:        Payroll State:        Payroll Zip:   

Length Of Employment:        Job Title:   

Do you regularly receive paystubs or other evidence of your wages from your employer?     Please Select Yes No N/A

How often do you get paid?    Please Select Weekly Bi-Weekly Semi-Monthly Monthly

GROSS INCOME (before deductions) per pay period (including over time pay):   

Take home (after deductions) per pay period:   

Payroll deductions other than taxes and social security:

401(k)   Retirement Plan   Child Support   Union Dues    Uniforms   
Additional Deductions

Other Regular Income (Monthly Average):   

Source(s) of other income:   

What was the last year that you filed a tax return?:   

What state did you live in when you filed it?:   

The last year you were required to file a return?:   

Did you file all tax returns for the past 4 years?:    Please Select Yes No

Do you own any interest in an education individual retirement account or a qualified state tuition program?:    Please Select Yes No

Next you will be asked to list all of your debts.  If your list is partially complete, then the information received in your consultation will be partially correct!!!