IntakeForm IV

Own Real Estate Select Yes No Mortgage Up to date Select Yes No No mortgage I rent Not Applicable Own Car Select Yes No Car payments up to date Select Yes No No Loan I own I lease Not applicable Employed Select Yes No Your pay period Select No pay period Every week Every other week Monthly quarterly not applicable Your Gross Pay Monthly Spouse pay period Select No pay period Every week Every other week Monthly quarterly not applicable Spouse Gross Pay Monthly Credit card debt Amount Select None Under $5000 $5000-$10,000 $10,000-20,000 $20,000-$30,000 $30,000-$40,000 $40,000-$50,000 Over $50,000 Amount pay credit card monthly Medical bills Amount Select None Under $5000 $5000-$10,000 $10,000-20,000 $20,000-$30,000 $30,000-$40,000 $40,000-$50,000 Over $50,000 Amount pay Medical bills monthly Judgements Amount Select None Under $5000 $5000-$10,000 $10,000-20,000 $20,000-$30,000 $30,000-$40,000 $40,000-$50,000 Over $50,000 Amount pay Jedgements monthly Student Loans Amount Amount pay Student loans monthly Tax Debts Amount Select None Under $5000 $5000-$10,000 $10,000-20,000 $20,000-$30,000 $30,000-$40,000 $40,000-$50,000 Over $50,000 Amount pay tax debts monthly Government Fines Amount Select None Under $5000 $5000-$10,000 $10,000-20,000 $20,000-$30,000 $30,000-$40,000 $40,000-$50,000 Over $50,000 Amount pay government fines monthly Personal Loans Amount Select None Under $5000 $5000-$10,000 $10,000-20,000 $20,000-$30,000 $30,000-$40,000 $40,000-$50,000 Over $50,000 Amount pay Personal loans monthly Hardship1 Select Law Suit Court Order Lien Garnishment Foreclosure Eviction Other Hardship2 Select Law Suit Court Order Lien Garnishment Foreclosure Eviction Other Hardship3 Select Law Suit Court Order Lien Garnishment Foreclosure Eviction Other Note