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Co-Debtor's/Spouse's Information

Name and Address

First Name

Middle Name

Last Name

Suffix

Cell: (123) 456-7890

Date of Birth: (MM/DD/YYYY)

Your Average Gross Monthly Income (Gross Income is Before Taxes)

$ Your Average Gross Monthly Income (Gross Income is Before Taxes)

Self Employed/ Business Net profit per mo

$ Self Employed/ Business Net profit per mo

Spouse:

Unemployed

W-2 Employee

Self Employed

Your Spouse's Average Gross Monthly Income (Gross Income is Before Taxes)

$ Your Spouse's Average Gross Monthly Income (Gross Income is Before Taxes)

Self Employed/ Business Net profit per mo

$ Self Employed/ Business Net profit per mo

Do you have a loan on this property?

Yes

You can find out the value of your home here zillow.com and/or redfin.com

$ Est. Mortgage - 1st Amount Owed

$ Monthly Payment - 1st

$ Est. Past Due Payments - 1st

If your current on this mortgage type in $0.00

$ Value of Property

Creditor Name

Street Address

City

State

Zip code

Do you have additional loans?

Yes

$ Est. Mortgage - 2nd Amount Owed

$ Monthly Payment - 2nd

$ Est. Past Due Payments - 2nd

If your current on this mortgage type in $0.00

Creditor Name

Street Address

City

State

Zip code

Do you have additional loans?

Yes

$ Est. Mortgage - 3rd Amount Owed

$ Monthly Payment - 3rd

$ Est. Past Due Payments - 3rd

If your current on this mortgage type in $0.00

Creditor Name

Street Address

City

State

Zip code

(LIST ALL VEHICLES YOU OWN, WHETHER YOU OWE MONEY ON THEM OR NOT)
(Please list any & ALL types of property listed above you possess, own or use even if you're not on the title or registration.)

Yes

Please list all cars, trucks, motorcycles, boats or aircraft where your name is on the registration.

Vehicle 1 Click to get value here kbb.com and/or nada.com

(Examples: Boats, trailers, motors, personal watercraft, fishing vessels, snowmobiles, motorcycle accessories)

$ Estimated Value of Property

Year

Make

Model

Mileage

Style of Vehicle

Do you have a loan on this property?

Yes

$ Monthly payment amount

$ Past due payment

$ Estimated Amount Owed

Creditor Name

Street Address

City

State

Zip code

Secured Loan 1:

Creditor Name

Street Address

City

State

Zip code

Property Description:

$ Monthly Payment Amount

$ Amount due

Date: (MM/YYYY)

Secured Loan 2:

Creditor Name

Street Address

City

State

Zip code

Property Description:

$ Monthly Payment Amount

$ Amount due

Date: (MM/YYYY)

Secured Loan 3:

Creditor Name

Street Address

City

State

Zip code

Property Description:

$ Monthly Payment Amount

$ Amount due

Date: (MM/YYYY)

Secured Loan 4:

Creditor Name

Street Address

City

State

Zip code

Property Description:

$ Monthly Payment Amount

$ Amount due

Date: (MM/YYYY)

$ Estimated Amount Due

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Client Intake Form

Debtor's Basic Information

Co-Debtor's/Spouse's Information

Income

Mortgages:

Vehicles/ Motorcycles/ Boats etc.:

Other Secured Loans:

Back taxes owed

Other Debts