Please supply the following information which will be of assistance in answering your questions and concerns. You can, of course, consider Alternatives. The information you supply is CONFIDENTIAL. When you have completed this form, mail or fax it to the following address: Edmund Dechant, Attorney at Law, Post Office Box 1708, Santa Rosa, CA 95402-1708, Voice (707) 604-0042 or Fax (707) 869-1118 (Due to this page's frameset design, you must use the printing option "print each frame separately" or copy the text to your word processing program to print). Date______________ How did you find out about Isbankrutpcyforme.com?___________________ Your Name _______________________________ Your Spouse's Name______________________ Your Marital Status: Married___Divorced___Single___Widowed___No. Of Dependents___ Your Mailing Address_______________________________________________________ Your Residence Address if Different ___________________________________________ Husband's Telephone Home______________________ Work ____________________ Wife's Home______________________ Work ____________________ Husband's Occupation______________ Employer ____________________ Length ______ Net Monthly ________ Wife's Occupation______________ Employer ____________________ Length ______ Net Monthly ____________ Other Income Source__________Net Monthly _________ Average Monthly Expenses ____________________ Special Concerns: (Circle Concerns) Loss of Job Bothered by creditors Being Sued...Served on________ Wages attached___As of_______ Vehicle Repossessed on_______ Behind on house payments House in foreclosure Are you in business? Yes___No___ Have you been in business in the last two years? Yes___No___ If so, type of business ______________________________________ If so, Are there any business Debts? Yes___No__ Please indicate if you have any of the following problems by entering yes or no and approximate amount: Prior Bankruptcy Filings Yes___ No___ Year________ Co-Signed Debts Yes__No__ Personal Injury /other Suits brought by you: Yes__ No__ Have you received or expect to receive in the near future an Inheritances Yes__No__ Have you sold or given away property within last 12 months? Yes__No__ Do you owe wages to any person? Yes__ No__ Were you a driver in a drunk driving accidents? Yes__ No__ Have you caused any intentional injury or damage to another? Yes__ No__ Do you owe Fed Taxes? Yes__ No__If yes: $_________Year___; Do you owe State Taxes? Yes__No__ If yes: $___________ Year_____ Other Taxes Yes__No__ If yes : $_________Year___ Do you owe Support for any person? Yes__No__ If yes: $___________ Year_____ Do you owe for Student Loans? Yes__No__ If yes :$_________ Do you owe any Fines? Yes__ No__; If yes: $_________ What were the fines for? _________________ Have you used Credit Cards used in last 60 days? Yes__No__ If yes: $_______________ Please Estimate your total Credit Card Debt:_________________________ Please Estimate your total number of Creditors: ____________________ Please Estimate your total other Debt:_________________________ Do you own Real Property (a home, building, or lot)? Yes___No__ List the Fair Market Value ___________________ Are any mortgages owed on the property? Yes__No__ Name of First Mortgager ______________________ Total Amount Owed _________ Are you current? Yes__No__ Name of Second Mortgager ____________________ Total Amount Owed __________ Are you current? Yes__No__ Name of Third Mortgager ______________________ Total Amount Owed __________ Are you current? Yes__No__ If you are not current, please list the amount you are behind on each loan: 1st:____________ 2nd:_____________3rd:_________________ Date of Foreclosure Notice:__________Sale Date:_______ Do you own an interest in other Real Property? Yes__No__ Explain: Do you own Vehicles? Yes__No__ If so, please list the following: 1. Year & Make ___________________ Monthly Payment __________ Paid Off?__ Creditor: ______________________ Amount Owed ________ Fair Market Value___________ 2. Year & Make ___________________ Monthly Payment __________ Paid Off?__ Creditor: ______________________ Amount Owed ________Fair Market Value___________ 3. Year & Make ___________________ Monthly Payment __________ Paid Off?__ Creditor: ______________________ Amount Owed ________Fair Market Value___________ Do you own items of Personal Property worth more than $500.00 each? Yes__No__ If so, please make a list of such property and indicate the fair market value of each item? __________________________________________________________________ Dear Mr. Dechant: I am interested in finding out how filing bankruptcy would improve my financial affairs. I understand that your review of this material is at no charge to me, and I assure you that the information I have given on this form is truthful and pertains to me. I understand that until I sign a written contract with you or another attorney concerning this matter, I am not represented by an attorney. I understand that until a bankruptcy is filed on my behalf, I am not protected from actions by my creditors even though I may have submitted this form and spoken with an attorney. Signed:_____________________(Print your Name)_________________ The best time to call me is:__________at (telephone No.): ____________________