Name *

First Name

Last Name

Best phone number to contact you at

(###)

###

####

Home address

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Have you been involved in a Bankruptcy in the last 8 years?

Yes

No

Have you lived in Western Washington the preceding 3 years?

Yes

No

Are you self employed?

Yes

No

Are you (or spouse) a disabled veteran, served in the armed forces or performed homeland security defense activities since 1993?

Yes

No

Have you (or spouse) been previously married in the last 8 years?

Yes

No

Spouse's Name

First Name

Last Name

Do you owe money on a home, land or any real estate?

Yes

No

Do you owe money on a car, boat, motorcycle, airplane, etc?

Yes

No

Do you owe any money to the IRS or any other taxing authority?

Yes

No

Not Sure

Do you owe any money to a finance company or credit union?

Yes

No

Do you owe any student loans?

Yes

No

Not Sure

Do you owe any money to a payday loan company?

Yes

No

Not Sure

Do you have any judgments against you?

Yes

No

Not Sure

Do you owe any current or back due child support, alimony, maintenance or property settlement?

Yes

No

Not Sure

Have you cosigned a debt for anyone?

Yes

No

Not Sure

Is anyone else liable for any of your debts?

Yes

No

Not Sure

Do you owe money to any relative?

Yes

No

Not Sure

Have you repaid any money to a relative in the past 12 months?

Yes

No

Not Sure

Does anyone claim you defrauded them?

Yes

No

Not Sure

Does anyone claim that you gave them a false financial statement?

Yes

No

Not Sure

Do you have copies of the last 2 federal income tax returns you have filed?

Yes

No

Not Sure

Have you filed all required federal income tax returns?

Yes

No

Not Sure

Have any tax liens been filed against you?

Yes

No

Not Sure

Have you made any balance transfers between credit cards within the last 90 days?

Yes

No

Not Sure

Do you owe money to a financial institution in which you have funds (checking, savings, cd, etc.)?

Yes

No

Not Sure

Do you believe your debt is primilarly consumer debt or business debt?

Consumer

Business

Within the last 12 months have you paid any money to relatives

Yes

No

Not Sure

Within the last 12 months have you transferred any property to a relative as payment of a debt?

Yes No Not Sure

Within the last 12 months have you been involved in any lawsuit, court action or administrative proceeding

Yes

No

Not Sure

Within the last 12 months has any of your property been repossessed, foreclosed upon, garnished, attached, seized or levied upon?

Yes

No

Not Sure

Within the last 90 days has any creditor set off or otherwise taken anything from any account?

Yes

No

Not Sure

Within the last 12 months has any of your property in the possession of an assignee for the benefit of creditors, court appointed receiver or custodian?

Yes

No

Not Sure

Within the last 24 months have you made a gift to anyone of more than $600?

Yes

No

Not Sure

Within the last 24 months have you given any money or property to a charity totaling more than $600?

Yes

No

Not Sure

Within the last 12 months did you lose anything because of fire, theft, or other disaster or gambling?

Yes

No

Not Sure

Do you have any money , property, furniture, etc. that belongs to another person or that you are holding for the benefit of someone else?

Yes

No

Not Sure

Did you purchase or refinance a car or truck or other vehicle on the past year?

Yes

No

Is any of your property in possession of a pawnbroker, storage company or repairman?

YesNo

Within the last 12 months have transferred any property or money to anyone concerning the filing of a bankruptcy proceeding?

Yes

No

Not Sure

Within last 12 months did you transfer any property or money to anyone who promised to help you deal with creditors?

Yes

No

Not Sure

With the last 24 months did you sell, trade or otherwise transfer any property to anyone? For example, did you sell a car, a house etc?

Yes

No

Not Sure

Within the last 10 years did you transfer any property or money into a self-settled trust?

Yes

No

Not Sure

Within the last 12 months were any of your financial accounts closed, sold, moved or transferred?

Yes

No

Not Sure

Now or within the last 12 months have you had a safety deposit box?

Yes

No

Not Sure

Within the last year have you had a storage unit?

Yes

No

Not Sure

Do you hold or control any property belonging to anyone else?

Yes

No

Not Sure

Has any governmental unit notified you that you might be liable for any violation of any environmental law?

Yes

No

Not Sure

Within the last 4 years have you owned a business as a sole proprietorship, LLC, partnership, corporation or have you been an officer, managing executive of a corporation?

Yes

No

Not Sure

Within the last 2 years have you given anyone a financial statement?

Yes

No

Not Sure

Have you or any of your children been involved in an automobile accident or injured for any reason in the last 2 years?

Yes

No

Not Sure

Is your or spouse's driver's license suspended?

Yes

No

Not Sure

Do you have an interest in a timeshare or vacation plan?

Yes

No

Not Sure

In the last 90 days have you gotten cash advances on your credit cards of more than $750?

Yes

No

Not Sure