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JEFFREY S. POSIN, ESQ. *ALSO MEMBER OF ARIZONA BAR
INFORMATION SHEET
Today’s Date_________________
A. PERSONAL INFORMATION
Mr. Mrs. Ms. ____________________________ Your Social Security No. ______________________ Date of Birth ____________
Spouse _________________________________ Spouse’s Soc. Sec. No. _______________________ Date of Birth ____________
Address ________________________________ City ____________________________________ State _____ Zip ___________
County _________________________________ Home Phone ___________________________ Cell Phone __________________
E-Mail Address ______________________________________
Dependents? Name & Age _____________________________________________________________________________________
How did you hear about our firm? _______________________________________________________________________________
Do you know any individual(s) that our firm is representing or has represented?_______ If yes, who? _________________________
Marital Status __________
Name of your Employer __________________________________ How long? ________ Work Phone No ______________
Your Occupation __________________________________________
Name of Spouse’s Employer ______________________________ How long? _________ Work Phone No ______________
Spouse’s Occupation _______________________________________
(Please choose a response for the following questions)
Do you: ______ your home Are you behind in house or rent payments? _______ How Many? ___________
Do you owe IRS or STATE taxes? _______ How much to IRS $ _______________ State $ ____________________
Do you owe student loans? _______ If yes, how many student loans? _____ How much $______________
Are you behind in child support? _______ How much $ _____________
Are you behind in spousal support? _______ How much $_____________
Have you had any credit card cash advances in the last six (6) months? _______
Do you have any NSF/Bounced Checks outstanding? _______
If yes, have they been turned over to the District Attorney? _______
If yes, have they been turned over to a collection agency? _______
Have you been threatened with criminal prosecution for any debt? _______
*Use "TAB" key to navagate through fields. Hover mouse over field for tips on proper format of information on dates and numbers.*When form is complete, you can print it, bring it to your appointment and save time!
Are you in the military?
Are your wages being garnished or about to be garnished? _______
Do you have any pending lawsuits against you? ________
Do you have any outstanding judgments against you? _______
Are you suing anyone? (car accident, SS disability claim, workers comp, class action lawsuit, etc.) _______
Have you co-signed for a loan for anybody? _______
Do you have any rent-to own contracts, pawns, or check advance loans? _______
Have you sold or transferred any property within the last two (2) years? _______
Do you have any 401K, IRA, thrift savings or retirement plans? _______
Do you have any Stocks, investments or e-trade accounts? _______
Have you ever filed Chapter 7 Bankruptcy or Chapter 13 debt consolidation? _______
If yes, what year? _______ Chapter _______
B. SECURED DEBTS
HOME LOANS: _______ Property Address: _________________________________________________________
1st MTG Payments $__________/month Payoff Amount $___________________ Behind? _______
If yes, how many months _______
2nd MTG Payment? $_________/month Payoff Amount $____________________ Behind? _______
If yes, how many months _______
3rd MTG Payment? $________/month Payoff Amount $____________________ Behind? _______
Approximate Value of Property $______________________ Year Purchased _______ Purchase Price $_______________
SECOND HOME: _______ Property Address: ____________________________________________________________
1st MTG Payment $__________/month Payoff Amount $___________________ Behind? _______
If yes, how many months _______
2nd MTG Payment $__________/month Payoff Amount $____________________ Behind? _______
If yes, how many months _________
3rd MTG Payment $__________/month Payoff Amount $____________________ Behind? _______
Approximate Value of Property $______________________ Year Purchased _________ Purchase Price $_______________
Are you buying a Mobile Home? _______ If Yes: Year _________ Make_______________ Model ___________________
Payment $ _______________ Balance Owed $ _______________
Do you own or rent land? ______________ Payment $_______________ Balance Owed $___________________
Do you own or have any ownership interest in any other real estate? _______
Have you received a letter from an attorney advising of a foreclosure sale date? _______ Sale Date ______________________
C. VEHICLES: _______
Status ______________ Pymnt $ ____________ Balance $_______________ 1stAuto:Yr/Make _________________________
2ndAuto:Yr/Make _________________________
3rdAuto:Yr/Make _________________________
4thAuto:Yr/Make _________________________
Status ______________Pymnt $ ___________ Balance $_______________
Status ______________ Pymnt $ ____________ Balance $_______________
Status ______________ Pymnt $ ____________ Balance $_______________
Are you behind on any car payments? _______ How many? _______
Date of most recent vehicle purchased? __________
D. INCOME:
Income: YOUR TOTAL GROSS monthly income (before taxes) from employment? $_________________
SPOUSES TOTAL GROSS monthly income (before taxes) from employment? $_________________
Monthly income from child support/alimony $_________________
Monthly income from Retirement $_________________
Other monthly income from _____________________________ $_________________
TOTAL MONTHLY INCOME $_________________
Your average income for the LAST SIX MONTHS $_______________/month
I get paid: _______________
My TAKE HOME pay per period is $ ________________
My LAST pay date was ___________________________ My NEXT pay date is __________________
My Spouse gets paid: _______________
My SPOUSE’S TAKE HOME pay per period is $ _______________
My SPOUSE’S LAST pay date was _______________________ My SPOUSE’S NEXT pay date is: __________
PLEASE FILL OUT THE FOLLOWING TWO PAGES TO THE BEST OF YOUR ABILITY. IF YOU DON’T KNOW THE EXACT AMOUNTS PLEASE USE YOUR BEST ESTIMATE.
E. EXPENSES
Enter estimated average current monthly expenses for you and your spouse:
Rent, Mortgage, or Mobile Home payment $ Real estate taxes (if not included in payments) $ Property insurance (if not included in payments) $ Lot rent for mobile home (if applicable) $ Electricity and Gas $ Water and Sewer $ Telephone and Cell Phone $ Garbage $ Cable $ Security $ Other Utilities $ Home Maintenance $ Food $ Clothing $ Laundry & Dry Cleaning $ Medical, Dental, Medication (Out of pocket including co-pays) $ Transportation (Gas, oil, maintenance, taxi and bus fares, NOT including car payments) $ Recreation, Entertainment, etc. $ Charitable contributions (Not deducted from paycheck) $ Homeowners/Renters insurance (Not deducted from paycheck) $ Life insurance (Not deducted from paycheck) $ Health insurance (Not deducted from paycheck) $ Auto insurance (Not deducted from paycheck) $ Disability insurance (Not deducted from paycheck) $ Other insurance (Not deducted from paycheck) $ Taxes NOT deducted from wages or included in home payments $ Auto payments (Total all car payments) $ Expenses for operation of a business, profession, or farm $ Alimony, child support, and maintenance paid to others $ Care for elderly, chronically ill, or disabled family members $ Child care $ Other expenses $
$ $ $
TOTAL
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