Debtor/Creditor Contact Form

Are you representing yourself or your business?
Self  Business 

Name(s), including middle initial

Email Address

Phone Number

Business Phone

Cellular or Pager

Other Phone

Residence address, including county

City

State

Zip

If you are representing a business, what is the business name?

Business address, including county

What type of business is it? (solo proprietorship, LLC, etc.)

Have you used any other personal or business name(s) in the last six years?
Yes  No 

If yes, please list here:

If you are representing a business, do customers or others owe your business money?
Yes  No 

If yes, please describe the circumstances and amounts involved:

Are any of these amounts secured by a UCC filing or other means?
Yes  No 

If yes, please describe:

Do you or your business owe any money to the Internal Revenue Service?
Yes  No 

If yes, for what year(s)?

How much?

Do you or your business have any unpaid loans?
Yes  No 

Amount $

Monthly Expenses

Do you have other financial obligations?
Yes  No 

If yes, to whom and how much?

Do you own or are you purchasing a home or other real property?
Yes  No 

Tax assessed value
$

First Mortgage Loan Balance
$

Loan Current?

Amount Behind
$

2nd Mortgage Loan Balance
$

Loan Current?

Amount Behind
$

3rd Mortgage Loan Balance
$

Loan Current?

Amount Behind
$

Are you facing foreclosure?
Yes  No 

Foreclosure Date

List any liens against your property

List all vehicle loans (cars, trucks, motorcycles, etc.; identify vehicle type)

Est. Loan Balance
$

Loan Current?
Yes  No 

Have you purchased any secured items in the last two years on which you still owe money?
Yes  No 

Have you taken out a loan from a finance company, credit union, bank or any other place and secured the loan by property or other type of secured collateral?
Yes  No 

Creditors' Names

Estimate balances owed on all other types of debt
$

List all judgments, lawsuits, liens and garnishments against you or your business

List all other assets not disclosed above.

Special concerns

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