v. 8.14.17

Instructions:

As you work through it there is something you don't know or understand leave it blank or type in "Unsure" and we can discuss it when we contact you.

This questionnaire will take you about 20 to 30 minutes to complete.  This form cannot be saved. DO NOT USE THE BACK BUTTON


Section I - Your Personal and Contact Information:

First Name

Middle Name

Last Name

Cell phone *Email 

 

Mailing address:

   Apt.

City   State   Zip

Date of birth mm/dd/yyyy

My Social Security number is:

Would you like for us to set your account up to receive text-alerts as your case proceeds?

Text alerts are a wonderful way to keep up to date on the status of your case with Discount Divorce & Bankruptcy


Section 2 - If Married and Filing Together: Spouse Contact Information:

First Name

Middle Name

Last Name

Date of birth mm/dd/yyyy

My spouse's Social Security number is:

If filing jointly is your spouse's address the same as yours?


Section 3 - Your Filing and Marital Status


Section 4 - Means Test

What was your average monthly gross (before deductions) income from the last six months (Do not include any income from Social Security)?

$ per month.

How many dependants living with do you have?

 

If filing jointly and living together, what was your spouses average monthly gross (before deductions) income from the last six months

(Do not include any income from Social Security)?

$ per month.

 


Section 5 - Real Property

Do you own any real property (home, land, etc.) .

If yes, what where is it located?

Address:

City: State: Zip:

 What is its market value? $

 What is the mortgage payoff amount? $

 Do you want to keep the home or surrender it back to the mortgage company?

Who is the lender?

What is their mailing address?

Address:

City: State: Zip:

There is a consignor for this mortgage.

 


Section 6 - Financial Accounts

I do not have a checking and/or savings account.

Account No. 1

If you have a checking or savings account, what is the name of the bank the account is with?

What is the balance of the account? $  What type of account: Checking Savings

Account No. 2

If you have a checking or savings account, what is the name of the bank the account is with?

What is the balance of the account? $  What type of account: Checking Savings

I have more bank accounts

Retirement Account

I do not have a retirement account such as a 401(k), IRA, 403(b), 409A, 457 Plans, ect.

If you do own a retirement account such as a 401(k), IRA, 403(b), 409A, 457 Plans, ect what is the name of the plan?

What is the balance of the account? $

What type of account is it?

I have another retirement account

 


Section 7- Personal Property

A. Do you own any household items (furniture, major appliances, dishes, etc.)?

     If yes, what is the fair market value of all the household items $

B. Do you own any electronic devices (cell phone, computer, television, etc.)?

     If yes, what is the replacement value of all your electronic devices. $

C. Do you own any antiques, paintings, prints, or other artwork; books, stamp, coin, baseball card collections or other collectables?

     If yes, what is the replacement value of your collection(s). $

D. Do you own any sports, photographic, exercise, and or other hobby equipment?

     If yes, what is the replacement value of your equipment? $

E. Do you own any firearms?

     If yes, what is the replacement value of your firearms? $ 

F. What is the replacement value of your personal clothing? $

G. Do you own any jewelry such as wedding or engagement rings, watches, gems, gold, silver, etc. (do not include costume jewelry)?

     If yes, what is the replacement value of your jewelry? $

H. Do you own any animals such as a dog, cat, bird, horse, etc.

     If yes, how many and what kind of animal(s) do you own: Describe:

     If yes, what is the replacement value of your animal(s)? $

 


Section 8 - Motor Vehicles

Do you own or are you on the registration on any cars, trucks, watercraft, aircraft, trailers, campers, RV's, ATV's, or motorcycles? .

     If yes,:

Vehicle No. 1: Make Model Year Mileage: .

What is the replacement value $ .

Is there a loan on this vehicle?

If yes, who is the lender? .

There is a consignor for this vehicle

If yes do you want to keep or surrender the vehicle?

 

Do you own or are you on the registration on any other cars, trucks, watercraft, aircraft, trailers, campers, RV's, ATV's, or motorcycles? .

     If yes,:

 

Vehicle No. 2: Make Model Year Mileage: .

What is the replacement value $ .

Is there a loan on this vehicle?

If yes, who is the lender? .

There is a consignor for this vehicle

If yes do you want to keep or surrender the vehicle?

 

Do you have additional cars, trucks, watercraft, aircraft, trailers, campers, RV's, ATV's, or motorcycles?


Section 9 - Taxes

A. Do you have any tax debt?

    If yes, who do you owe back taxes too? .

     If, yes how much is owed? $ .

B. Do you owe any other tax debt?

     If yes, who do you owe back taxes too? .

     If, yes how much is owed? $

C. Are you expecting a tax refund?

     If yes, who are you expecting a refund from? State Federal (IRS)

     If you checked from state, how much are you expecting? $

     If you checked from IRS, how much are you expecting? $

 


Section 10 - Lease Agreements

Are you leasing a home or apartment?

If yes, who is your landlord?

Address:

City: State: Zip:

I have received an eviction notice:

 


Section 11 - Business Ownership

Have you owned any interest in any business in the past 4 years?

If yes, what is the name of the business?

If yes, what type of business entity was (is) it?

 


Section 12 - Income

Are you employed?

If you (or your spouse if filing jointly) are NOT employed skip to Section 13, "Expenses"

If you are filing jointly also complete the information regarding your spouse too.

 

What is your occupation? Spouse's occupation?

 

Employer?

Employer's address:

City: State: Zip:

 

Spouse's Employer?

Spouse's employer's address:

City: State: Zip:

 

I or my spouse have another job(s)

Income:

Gross (before deductions) monthly wages, salary, and commissions? My $ My Spouse's $

Estimated monthly overtime pay? $ My Spouse's $

Deductions:

How much is deducted from your pay for:

A. Taxes, Medicare, and Social Security each month? $ My Spouse's $

B. Mandatory contributions for retirement each month? $ My Spouse's $

C. Voluntary contributions for retirement each month? $ My Spouse's $

D. Required repayments of retirement loans each month? $ My Spouse's $

E. Insurance each month? $ My Spouse's $

F. Domestic support obligations (child support / alimony) each month? $ My Spouse's $

G. Union dues each month? $ My Spouse's $

H. Other deduction each month? $ My Spouse's $

Other Income

What is your monthly income from:

A. Rental property or from the operation of a business per month? $ My Spouse's $

B. Child support or alimony per month? $ My Spouse's $

C. Unemployment compensation per month? $ My Spouse's $

D. Social Security per month? $ My Spouse's $

E. Other government assistance per month? $ My Spouse's $

F. Pension or retirement per month? $ My Spouse's $

G. Any other income per month? $ My Spouse's $

I expect my income to over the next year.

 


Section 13 - Expenses

If you have no expenses go to Section 14, "Residency History"

I have

If you have dependants complete the following:

Dependant No. 1 Age Does this dependant live with you?

Dependant No. 2 Age Does this dependant live with you?

Dependant No. 3 Age Does this dependant live with you?

Dependant No. 4 Age Does this dependant live with you?

Dependant No. 5 Age Does this dependant live with you?

Dependant No. 6 Age Does this dependant live with you?

 

What are you expenses for the following:

A. Rent or mortgage per month? $

B. Real estate taxes per month? $

C. Property, homeowner's, or renter's insurance per month? $

D. Home maintenance, repair, and upkeep per month? $

E. HOA or condo dues per month? $

F. Additional mortgage payments such as home equity loans per month? $

G. Electric, heat, and natural gas per month? $

H. Water, sewage, garbage collection per month? $

I. Telephone, cellular, internet, satellite, and cable per month? $

J. Other utility per month? $

K. Food and housekeeping supplies per month? $

L. Childcare and child education costs per month? $

M. Clothing, laundry, and dry cleaning per month? $

N. Personal care products and services per month? $

O. Medical and dental per month? $

P. Transportation: Gas, maintenance, bus and train fair per month? $

Q. Entertainment: Clubs, recreation, newspapers, etc. per month? $

R. Charitable contributions per month? $

S. Life insurance? $

T. Health insurance (not deducted from pay)? $

U. Vehicle insurance per month? $

V. Other insurance per month? $

W. Taxes (not deducted from pay) per month? $

X. Car payment (vehicle 1) per month? $

Y. Car payment (vehicle 2) per month? $

Z. Payments for alimony, child support, other obligations not deducted from pay? $

AA. Other expenses per month? $

I have other real property payments not included above.

I expect my expenses to over the next year.

 


Section 14 - Residency History

During the past 3 years I have lived somewhere other than where I live now.

If you did not check the box above go to Section 15, "Income Earned"

If you did check the box above complete the following:

Home No. 1

Address:

City: State: Zip:

Date moved in? mm/yyyy

Date moved out? mm/yyyy

 

Home No. 2

Address:

City: State: Zip:

Date moved in? mm/yyyy

Date moved out? mm/yyyy

 


Section 15 - Income Earned

I had NO income from the employment or the operation of a business during the last 2 calendar years.

If you had income complete the following:

Income for 2017 $ Year to date

Income for 2016 $

Income for 2015 $

 

I had NO income from one or more of the following: Pension, Social Security and/or unemployment benefits during the last 2 calendar years.

If you had income complete the following:

Income for 2017 $ Year to date

Income for 2016 $

Income for 2015 $

 


Section 16 - Financial Affairs

A. During the past 90 days I had paid a creditor $600 or more.

B. Within the past 12 months I have been a party in a lawsuit, court action or an administrative proceeding.

C. Within the past 12 months I have had property repossessed, foreclosed, garnished, attached, seized, or levied.

D. Within the past 12 months I closed a financial account.

E. During the past 8 years I had gone by another name (maiden name, etc).

If you checked the above box in 16(E) what was that name?

 


Section 17 - Court's Filing Fee

The Bankruptcy Court charges a $335 filing fee to issue you a case number.

I want to make payments on the filing fee.

 


Section 18 - Disclosers

You must check ALL boxes for us to begin work on your case.

A. I certify that all information contained herein is accurate to the best of my belief.

B. I acknowledge that purposely misleading the Court is a crime.

C. I acknowledge that Discount Divorce Pro., LLC is not a law firm and cannot give me legal advice.

D. I acknowledge that all fees are earned when paid and that there are no refunds.

E. I acknowledge that I am responsible for proof reading my documents once they have been prepared.

F. I acknowledge that there may be additional costs and fees should I want to amend my documents once they have been prepared.

G. I acknowledge that I have read the Terms of Service and agree with them.  Terms of Service (opens in a new window)

H. I have NOT filed a Chapter 7 Bankruptcy in the past 8 years.

 


Section 19 - E-Signature

 

Applicant Name/E-Signature:

Date (mm/dd/yyyy):

 


Section 20 - Payment Information

All costs will be discussed with you in advance, and we will not proceed or charge your card until you instruct us to do so.

 

Number Exp. Date

CVV No. What is a CVV Number? (opens a separate window) Type of Card

Amount that will be charged after speaking with a Representative will be $199.