Client Questionnaire

Iowa Bankruptcy

Edward F. Noyes

Please contact us by calling (800) 875-7148 to schedule your free 1 hour initial consultation before filling out this form.

Personal Information

First Name:
Last Name:
Email:
Phone Number:
Cell Phone Number:
Address:
City:
State:
Zip Code:

Spouse Information

First Name:
Last Name:
Address:
City:
State:
Zip Code:
Have you or your spouse used any other names in the last 8 years? If so, please list.
How many people live in your home that you claim as dependents?
Has anyone started legal proceedings against you?
Do you expect to receive any sums of money, or any other property within the next year, which are not related to your normal income?
Are you anticipating an inheritance in the next year?

Property - Real Estate

Property type:
What company do you make your mortgage payments to?
What is the assessed value of your home?
How much do you still owe on your home?
Do you have a second morgage?
How much is your mortgage payment?
How much is your second mortgage payment?
Are you behind on your mortgage payments? If so, how many months are you behind?
What interest rate are you paying on your mortgage?

Bank Accounts

How many savings accounts do you own?
How many checking accounts do you own?
Do you have a safety deposit box?
If so, which bank?
Please provide details of the contents:

Personal Property

Estimated value of jewelry? (Specifically wedding rings)
Do you own any guns?
Do you own any sporting or hobby equipment? (eg., cameras, fishing equipment)
Do you own interest in any life insurance policies? Term life or whole life?
Do you own any annuities?
Do you have a pension, profit-sharing, or IRA plan?
Do you own stock in any companies?
Do you own any corporate or government bonds?
Does anyone owe you money? If so, how much?
Do you get any money in alimony or child support? If so, how much?
How often are you paid? Weekly, bi-weekly, semi-monthly, or monthly.
Are you expecting tax refunds in the next 3 months?
Do you anticipate receiving an inheritance?
Are you involved in a personal lawsuit?
Do you own any copyrights, patents, or intellectual property?
Do you own any franchise rights?
Do you own any address or e-mail address lists that could be sold?
Estimated value of any office equipment, supplies, furnishings, etc.?
Do you own any inventory in a product? If so, what is its estimated value?
Do you own any livestock, poultry, or other animals?
Do you have crops?
Do you own farming equipment? If so, what is its estimated value?
Do you own any farm supplies, chemicals, or feed? If so, what is there total estimated value?
Estimated value of any other personal property.
Do you have any leased vehicles or storage facilities?
How many vehicles do you own?
List any property (cars, home, household goods, etc.) that has been repossessed, sold at a foreclosure sale, transferred in lieu of foreclosure or returned to the seller, within the last year:

Debts

Please provide a rough estimate.
Credit card debt:
Medical debt:
Past utilities debt:
Personal unsecured loans:
Other debts:
Do any of your debts arise from:
A fine or penalty imposed by court?
Credit purchases of luxury goods or services in the last 90 days?
Loans or cash advances in the last 70 days?
Debts from willful injury to another person or another person’s property?
Child support or alimony?
Student loans?
Recent income tax debts and all other tax debts?
Fraud, embezzlement, misappropriation?
Debt for personally injury or death caused by your intoxicated driving?
Obtaining property by false pretences/fraudulent misrepresentation?

Income

Net employment income:
Net employment income of spouse:
Net pensions/annuities:
Net child support:
Other net income:
Child tax benefit:
Net spousal support:
Net unemployment insurance benefits:
Net social assistance:
Net self employed income
If you have self employment income, how long have you been self employed?
Total net monthly income:
Does anyone owe you money?

Expenses

Living Expenses

Please list your monthly living expenses.
Mortgage or rent:
Property taxes and insurance (if not included in your rent/mortgage payment):
Electric and heating fuel:
Water and sewer:
Telephone (cell phone included):
Cable/Satellite TV, including Internet:
Home maintenance (repairs & upkeep):
Food:
Clothing:
Laundry and dry cleaning:
Medical and dental expenses:
Transportation (gas and vehicle upkeep expenses):
Recreation/entertainment:
Charitable contributions:

Insurance

Does not include insurance that is deducted from wages or home mortgage payments.
Homeowners or renters insurance:
Life insurance:
Health insurance:
Auto insurance:
Other insurance:

Taxes

Does not include taxes deduced from wages or home mortgage payments.
Property taxes:

Installment payments

Alimony, Maintenance and Support paid to others

Child support:
Alimony:
Other:

Misc

Business or profession expenses (truck driving payments, personal business expenses, farm, etc.):
Miscellaneous Expenses: