Name
Spouse
Address
Spouse Address (if different)
City/St/Zip
Home Phone
Spouse Home Phone (if different)
Cell Phone
Spouse Cell Phone
Email Address
Spouse Email Address
If Internet (Where?)
If Referral (Who?)
Have you ever filed Bankruptcy before?
If so, which chapter did you file and what was the date of filing?
How long have you lived in the state of New Mexico for
Have you been served a summons for a current court proceeding?
If so, please explain:
Are you currently being garnished?
If so, by whom?
Mortgage Co. Name:
2nd Mtg. Co. Name:
1st Mtg.
2nd Mtg.
1st Mtg. Payment
2nd Mtg. Payment
1st Mtg. Value
2nd Mtg. Value
1st Mtg. Payoff
2nd Mtg. Payoff
1st Mtg. Payments Behind
2nd Mtg. Payments Behind
Do you own any land or real estate, that you do not live on?
Are there any liens (tax or otherwise) on your home?
If so, please explain:
Vehicle 1 (yr., make & model)
Miles
Value
Total Owed
Mo. Payment
Payments Behind
Lender
Interest Rate
When Purchased (Mo/Yr)
Vehicle 2 (yr., make & model)
Miles
Value
Total Owed
Mo. Payment
Payments Behind
Lender
Interest Rate
When Purchased (Mo/Yr)
Vehicle 3 (yr., make & model)
Miles
Value
Total Owed
Mo. Payment
Payments Behind
Lender
Interest Rate
When Purchased (Mo/Yr)
Vehicle 4 (yr., make & model)
Miles
Value
Total Owed
Mo. Payment
Payments Behind
Lender
Interest Rate
When Purchased (Mo/Yr)
Do you own any of the following assets: Guns, High Value Hobby Equipment or Sporting Goods, Artwork, ATVs, Campers, Trailers, RVs, Airplanes, Boats? If so, please describe:
Are you involved in Worker’s Comp, Civil or Personal Injury lawsuit?
If so, please explain:
Are you current on your tax filings?
If not, what years are not filed?
Are you expecting a tax refund for ANY YEAR?
If so, when?
How much?
If you have ANY TAX DEBT, what years do you owe?
If you own a business, are you current on your CRS return filings?
Do you owe any student loans?
What is the total amount of your unsecured debt (i.e. Credit Cards, Medical Bills, Personal Loans):
How much is an average paycheck from employment or self-employment? How often are you paid?
Your Gross
Your Net
Spouses Gross
Spouses Net
Do you receive any income other than from employment (i.e. social security, disability, retirement)?
If so how much to you earn monthly?
Car payment:
Car Insurance:
Rent or Mortgage:
Food:
All Utilities (gas, electric, water, sewer, trash, etc.)
Medical (co-pays, deductibles, prescriptions, etc. on average):
Telephone:
Child Care:
Property Taxes: (don’t list if pd. In mtg. payment)
Child support:
Recreation:
Laundry:
Auto Expense (gas, oil changes, Repairs, tires, etc.
Student Loans
Charitable Contributions: (only those that can be proven)
Home Expenses/maintenance (only if you own):
Other Tax debt (describe):
Health Ins. not deducted from pay:
Clothing:
School Expenses:
Homeowners or Renters Insurance: (don’t list if pd. in mtg. payment)
Life Insurance (cash value?)
Miscellaneous:
Cable, Internet:
Debtor Signature
Date
Spouse Signature
Date
