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Fill in the Form Below to Get Back on the Road to Freedom

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

Note: please use your “tab” key to move to the next entry field. By pressing “return/enter” your form will automatically be submitted.

Personal Information
First Name
Last Name
Email
Phone
Cell Phone
Street Address
City
State
ZIP Code
Spouse Name
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?
Yes No
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?
Yes No
Are you anticipating an inheritance in the next year?
Yes No

Property – Real Estate
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?
How much is your mortgage payment?
Do you have a second mortgage?
Yes No
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?
Yes No
If so, at which bank?
Please provide details of the contents:

Personal Property
Estimated value of jewelry?
Do you own any guns?
Yes No
Do you own any sporting or hobby equipment?
Yes No
insurance policies? Term life or whole life?
Yes No
Do you own any annuities?
Yes No
Do you have a pension, profit-sharing, or IRA plan?
Yes No
Do you own stock in any companies?
Yes No
Do you own any corporate or government bonds?
Yes No
Does anyone owe you money? If so, how much?
child support? If so, how much?
How often are you paid?
Are you expecting tax refunds in the next 3 months?
Do you anticipate receiving an inheritance?
Yes No
Do you anticipate receiving an inheritance?
Yes No
Are you involved in a personal lawsuit?
Yes No
Do you own any copyrights, patents, or intellectual property?
Yes No
Do you own any franchise rights?
Yes No
Do you own any address or e-mail address lists that could be sol
Yes No
Estimated value of any office equipment, supplies, furnishings,
Do you own any inventory in a product? If so, what is its estima
Do you own any livestock, poultry, or other animals?
Yes No
Do you have crops?
Yes No
Do you own farming equipment? If so, what is its estimated value
arm supplies, chemicals, or feed? estimated value
Estimated value of any other personal property.
Do you have any leased vehicles or storage facilities?
Yes No
How many vehicles do you own?
List any property repossessed in the last year

Debts
Credit card debt: Estimate
Medical debt:
Past utilities debt:
Personal unsecured loans:
Other debts:
Do any of your debts arise from:
A fine or penalty imposed by court?
Yes No
Credit purchases of luxury goods or services in the last 90 days
Yes No
Loans or cash advances in the last 70 days?
Yes No
Child support or alimony?
Yes No
Student loans?
Yes No
Recent income tax debts and all other tax debts?
Yes No
Fraud, embezzlement, misappropriation?
Yes No
Debt for injury or death caused by your intoxicated driving?
Yes No
Obtaining property by false pretences/fraudulent misrepresentation?
Yes No

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
How long have you been self-employed?
Total net monthly income:
Does anyone owe you money?
Yes No

Expenses
Please list your monthly living expenses.
Mortgage or rent:
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
Homeowners or renters insurance:
Life insurance:
Health insurance:
Auto insurance:
Other insurance:
Property taxes:
Child support:
Alimony:
Other:
Business or profession expenses
Miscellaneous Expenses:


 

 

 

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Thank you for visiting the web site of Noyes Law Office, P.C. The materials in this web site have been provided by Noyes Law Office, P.C. for general information purposes only and are not legal advice. None of the information at this web site is intended to constitute, nor does it constitute, legal advice. Transmission of information from this site is not intended to create, and receipt does not constitute, an attorney-client relationship. You should not act upon this information without seeking professional advice. Due to the complexity of bankruptcy laws and differing interpretations of statute and case law from various state and federal courts, you should obtain the services of a competent bankruptcy attorney before acting upon the materials contained on this web site or filing a bankruptcy petition. For more information call Noyes Law Offices, P.C. at 104 1/2 North Main Street, Fairfield, IA 52556 | phone: 1-800-875-7148 | e-mail: ednoyes@natel.net