Initial Debt Management Questionnaire

Bold labels and indicate required information.

Preliminary Debt Management Questionnaire* Date: Please enter today's date.

Name: Please enter your name.

Other names you are also known as: Please enter other names you are also known as.

SSN: Please enter your social security number.

DOB: Please enter your date of birth.

How long have you been a resident of Missouri: Please enter how long you have been a resident of Missouri.

Spouse: Please enter the name of your spouse.

Other names your spouse is also known as: Please enter other names your spouse is also known as.

Spouse's SSN: Please enter your spouse's social security number.

Spouse's DOB: Please enter your spouse's date of birth.

How long have your spouse been a resident of Missouri: Please enter how long your spouse have been a resident of Missouri.

Address: Please enter your address.

City/State: Please enter your city and state.

Zip: Please enter your zip code.

Alternate mailing address: Please enter your alternate mailing address.

Email:

Please enter a valid e-mail address.

Work Phone:

Home Phone:

Cell:

Have you filed bankruptcy before?:

Have you filed bankruptcy before? Yes

Chapter: Please enter which bankruptcy chapter you filed.

Date of filing: Please enter the date you filed bankruptcy.

Renting Home Are you leasing your residence?:

Are you leasing your residence? Yes

Do you intend to assume/keep the lease?:

Do you intend to assume/keep the lease? Yes

Purchasing Home Name(s) on deed: Please enter the names on the deed.

Number of mortgages on property: Please enter the number of mortgages on property.

1st Lender: Please enter the first lender.

Monthly payment: Please enter the monthly payment on the first mortgage.

Balance owed: Please enter the balance owed on the first mortgage.

Payments behind: Please enter how many payments you're behind on the first mortgage.

Does mortgage include taxes?:

Does mortgage include taxes? Yes

Does mortgage include insurance?:

Does mortgage include insurance? Yes

2nd Lender: Please enter the second lender.

Monthly payment: Please enter the monthly payment on the second mortgage.

Balance owed: Please enter the balance owed on the second mortgage.

Payments behind: Please enter how many payments you're behind on the second mortgage.

Date purchased/refinanced: Please enter the date purchased/refinanced.

Purchase Price: Please enter the purchase price.

Fair Market Value: Please enter the fair market value.

Foreclosure date, if any: Please enter the date of foreclosure.

Foreclosing attorney name: Please enter the name of the foreclosing attorney.

Purchase of Other Real Estate Name(s) on deed: Please enter the names on the deed.

Number of mortgages on property: Please enter the number of mortgages on property.

1st Lender: Please enter the first lender.

Monthly payment: Please enter the monthly payment on the first mortgage.

Balance owed: Please enter the balance owed on the first mortgage.

Payments behind: Please enter how many payments you're behind on the first mortgage.

Does mortgage include taxes?:

Does mortgage include taxes? Yes

Does mortgage include insurance?:

Does mortgage include insurance? Yes

2nd Lender: Please enter the second lender.

Monthly payment: Please enter the monthly payment on the second mortgage.

Balance owed: Please enter the balance owed on the second mortgage.

Payments behind: Please enter how many payments you're behind on the second mortgage.

Date purchased/refinanced: Please enter the date purchased/refinanced.

Purchase Price: Please enter the purchase price.

Fair Market Value: Please enter the fair market value.

Foreclosure date, if any: Please enter the date of foreclosure.

Foreclosing attorney name: Please enter the name of the foreclosing attorney.

Vehicles - Cars/Boats/Motorcycles/
Trailers/Recreational Vehicles

Vehicle 1

Year: Please enter the year of your vehicle.

Make: Please enter the make of your vehicle.

Model: Please enter the model of your vehicle.

Type (e.g. truck, car, SUV, etc.): Please enter the type of your vehicle.

Name(s) on title: Please enter the name(s) on the title.

Current mileage: Please enter the current mileage of your vehicle.

FMV: Please enter the FMV.

Lender: Please enter the lender for your vehicle.

Monthly payment: Please enter the monthly payment for your vehicle.

Balance owed: Please enter the balance owed for your vehicle.

Payments behind: Please enter the number of payments you're behind for your vehicle.

Known defects at this time: Please enter the known defects at this time for your vehicle.

Date purchased: Please enter the date purchased for your vehicle.

Vehicle 2

Year: Please enter the year of your vehicle.

Make: Please enter the make of your vehicle.

Model: Please enter the model of your vehicle.

Type (e.g. truck, car, SUV, etc.): Please enter the type of your vehicle.

Name(s) on title: Please enter the name(s) on the title.

Current mileage: Please enter the current mileage of your vehicle.

FMV: Please enter the FMV.

Lender: Please enter the lender for your vehicle.

Monthly payment: Please enter the monthly payment for your vehicle.

Balance owed: Please enter the balance owed for your vehicle.

Payments behind: Please enter the number of payments you're behind for your vehicle.

Known defects at this time: Please enter the known defects at this time for your vehicle.

Date purchased: Please enter the date purchased for your vehicle.

Vehicle 3

Year: Please enter the year of your vehicle.

Make: Please enter the make of your vehicle.

Model: Please enter the model of your vehicle.

Type (e.g. truck, car, SUV, etc.): Please enter the type of your vehicle.

Name(s) on title: Please enter the name(s) on the title.

Current mileage: Please enter the current mileage of your vehicle.

FMV: Please enter the FMV.

Lender: Please enter the lender for your vehicle.

Monthly payment: Please enter the monthly payment for your vehicle.

Balance owed: Please enter the balance owed for your vehicle.

Payments behind: Please enter the number of payments you're behind for your vehicle.

Known defects at this time: Please enter the known defects at this time for your vehicle.

Date purchased: Please enter the date purchased for your vehicle.

Vehicle 4

Year: Please enter the year of your vehicle.

Make: Please enter the make of your vehicle.

Model: Please enter the model of your vehicle.

Type (e.g. truck, car, SUV, etc.): Please enter the type of your vehicle.

Name(s) on title: Please enter the name(s) on the title.

Current mileage: Please enter the current mileage of your vehicle.

FMV: Please enter the FMV.

Lender: Please enter the lender for your vehicle.

Monthly payment: Please enter the monthly payment for your vehicle.

Balance owed: Please enter the balance owed for your vehicle.

Payments behind: Please enter the number of payments you're behind for your vehicle.

Known defects at this time: Please enter the known defects at this time for your vehicle.

Date purchased: Please enter the date purchased for your vehicle.

Personal Property How much cash do you usually have on hand?: Please enter how much cash you usually have on hand.

List any bank accounts in your name by: bank name, type of account and an average daily balance for each. Please list any bank accounts in your name.

List any security deposits with a landlord or utility company by: amount and name of deposit holder. Please list any security deposits with a landlord or utility company.

Describe your household goods and provide current standard resale values for each item, identifying such items as furniture, appliances, etc. Please enter a description of your household goods.

List any books, pictures, antiques or Collections of worth with resale values. Please list any valuables.

Provide a resale value for your clothing. Please enter a resale value for your clothing.

List any furs or jewelry with resale values. Please list any furs or jewelry with resale values.

List any firearms, sports, photographic or other hobby equipment with resale values. Please list any firearms, sports or other hobby equipment with resale values.

List any interest in insurance policies by: insurance company, cash value and type (term or whole life). Please list any interest in insurance policies.

Do You Own or Have Any Interest in Any of the Following:

Any other personal property not already listed? If so, please itemize. Please enter any other personal property not listed above.

Other Property Issues Have you had a work-related injury or other medical condition within the last 2 years? If yes, have you filed a claim? Have you had any other injuries in the last 5 years? If yes, have you filed a claim? Have you transferred any property or money to another individual in the last 4 years? If so, explain:

Have you filed all tax returns that you are required to file?:

Have you filed all tax returns that you are required to file? Yes

If no, please indicate which year(s) need to be filed: Please indicate which year(s) need to be filed.

Were you/are you entitled to a tax refund?:

Were you/are you entitled to a tax refund? Yes

If yes, how much?: Please indicate how much tax refund you were entitled.

Other Debts-(Estimate if Unknown)

Total Credit Card Debt:

Total Personal Loan/Payday Loan Debt:

Total Medical Debt:

Total Tax Debt:

Total Credit Card Debt:

Child Support Arrearage Owed by You:

Other Debt (E.G. Repos, Past Due Utilities, Etc.):

Debts Owed to Family and/or Friends:

Secured Debt (e.g. Furniture, Jewelry, etc.):

Credit Card Issues Have you taken any cash advances in the last 70 days totaling $750 or more? If so, identify dates and amounts:

Have you made any luxury purchases in the last 90 days totaling $500 or more? If so, identify date(s), item(s) purchased and amounts:

Other Issues Do you owe money to the bank with which you also have a bank account?:

Do you owe money to the bank with which you also have a bank account? Yes

Have you signed any non-residential leases or rental agreements (e.g. Rent-A-Center, car, etc.)? If so, identify the items leased and the payment terms:

Provide full name(s) of any co-debtor(s) and identify which debt they owe jointly with you:

Household Information Current marital status: If divorced, year of the divorce decree:

Ages and relationships of all people living with you: Ages and relationships of all people living with you:

Dependents you will claim on your tax returns:

Please indicate any income received from people living with you:

Employment-Primary Employer name and address:

Job Title:

How often are you paid?: Length of time on the job:

Annual salary/hourly wage:

Gross paycheck before deductions:

Net paycheck after deductions:

Employment-2nd Job Employer name and address:

Job Title:

How often are you paid?: Length of time on the job:

Annual salary/hourly wage:

Gross paycheck before deductions:

Net paycheck after deductions:

Employment-Spouse Employer name and address:

Job Title:

How often are you paid?: Length of time on the job:

Annual salary/hourly wage:

Gross paycheck before deductions:

Net paycheck after deductions:

Employment-Spouse 2nd Job Employer name and address:

Job Title:

How often are you paid?: Length of time on the job:

Annual salary/hourly wage:

Gross paycheck before deductions:

Net paycheck after deductions:

Other Income Monthly income earned from business operations outside of paycheck.

Monthly income earned from real estate property.

Monthly income from alimony or family support payments.

Monthly income from Social Security.

Monthly income from Food Stamps.

Monthly income from Welfare or other public assistance.

Monthly income from retirement or pension.

Monthly contributions from family.

Monthly income from any other sources not listed.

Total Net Monthly Income

Are you or your spouse expecting an increase in income or expenses in the next year? If so, explain: Are you or your spouse expecting an increase in income or expenses in the next year? If so, explain:

Monthly Expenses-do Not Include Past Due Amounts Rent/Mortgage/Pad Rental

Electricity, Gas, Water, Sewer: Electricity:

Gas:

Water:

Sewer:

Telephone, Cell, Phone, Internet: Telephone:

Cell Phone:

Internet:

Trash, Cable, Security System, Beeper:

Trash:

Cable:

Security System:

Beeper:

Home Repairs (Only If You Are Purchasing/Own Your Home)

Food For You And Family

Clothing For You And Family

Laundry And Dry Cleaning For You And Family

Medical/Dental Expenses For You And Family

Gas And Repairs For Car(S) (Averaged On A Monthly Basis)

Recreation, Entertainment, Newspaper, Magazines, Etc.

Charitable Contributions

Homeowner's/Renters Insurance

Life Insurance

Health Insurance(Only If This Is Not Deducted From Your Paycheck)

Auto Insurance

Other Insurance Not Withheld From Paycheck

Other Taxes (Real Estate, Personal Property, Self-employment, Etc.)

Auto Installment Payment

Other Installment Payment

Alimony Or Child Support Due Monthly

Payment For Support Of Dependents Not Living At Home

Expenses From Business Or Profession

Petcare

Childcare Or Education Expenses For Children Under 18

Other Expenses:

A) Court Ordered Payments Not Already Listed

B) Education For A Physically/Mentally Challenged Child

C) Care For Elderly, Chronically Ill, Or Disabled Family

D) Protection From Family Violence

Total Monthly Expenses

*Additional information will be required before a final recommendation will be made by attorney/counselor

Law Offices of Steven K. Brown

Bankruptcy Newsletter

Workers' Compensation Newsletter

Chapter 7 Bankruptcy Eligibility

Discharge of Indebtedness

Dischargeable Debts

Nondischargeable Debts

Employer Misconduct

Evidence in Workers' Compensation Administrative Proceedings

Lien and Transfer Avoidance in Connection With Marital or Family Obligations

Information Needed to File Your Bankruptcy Petition

Initial Debt Management Questionnaire (PDF)