Case Evaluation

Bold labels and indicate required information.

Name

Enter the name

Email Address

Please enter a valid email address.

Phone

Enter the phone number

Do you intend to file a joint bankruptcy petition?

Yes No

If yes, include information for both yourself and your spouse below:

Name(s), including middle initial

*Residence address, including county

How long have you been at this address?

Address	How Long?

Other telephone number(s)

Work

Cell

Other

Have you used any other name(s) in the last six years?

Yes No

If yes, please list here

Marital Status

If married, how long?

If divorced, how long?

Ages of minor children living with you

Ages, and amount of child support paid:

Age	Amount
	$
	$
	$
	$

Is any child support past due?

Yes No
Amount

Husband's employment:
How long at this job?

Occupation

Income paid
Gross

Net

Wife's employment(name and addr.):
How long at this job?

Occupation

Income paid

Gross

Net

Income from other sources (second job, investments, social security, child support, worker's compensation, etc.) (state sources and amount):

Do you owe any money to the Internal Revenue Service?

Yes No

If yes, for what year(s)?

How much?

Do you have any unpaid student loans?

Yes No

Amount

Monthly Expenses

Rent		Real Estate Taxes
Electric		Home Maintenance
Gas		Life Insurance
Water		Health Insurance
Phone		Auto Insurance
Cable		Homeowner/Rent Ins.
Trash		House Payment

Do you pay anyone spousal support (alimony)

Yes No

If yes, to whom and how much?

Do you own or are you purchasing a home or other real property?

Yes No

Tax Assessed Value

First Mortgage Loan Balance

Loan Current?

Amount Behind

2nd Mortgage Loan Balance

Loan Current?

Amount Behind

3rd Mortgage Loan Balance

Loan current?

Amount Behind

Are you facing foreclosure?

Yes No

Foreclosure Date

List any liens against your property

List all vehicle loans (car, truck, motorcycles; identify vehicle type)

Vehicle	Est. Loan Balance	Loan Current	Amount Behind
	$	$	$
	$	$	$
	$	$	$

List all vehicles you own outright (no loan balance)

Vehicle	Est. Value
	$
	$

Have you purchased any secured items (electronics, boats, jet ski, appliances, etc.) in the last two years on which you still owe money?

Yes No

Have you taken out a loan from a finance company, credit union, bank or any other place and secured the loan by household items or other type of secured collateral?

Yes No

Creditors' Names

Estimate balances owed on all other types of debt listed below

$		Medical Bills
$		NSF Checks
$		Credit Cards
$		Misc. Bills

When was the last time you used any of your credit cards? (approx. date)

How much has total owed on cards gone up in the last 12 months?

Have you had any new cards issued in the last 12 months?

Do you anticipate receiving a tax refund?

Yes No

How much?

List all judgments, lawsuits, liens, and garnishments against you.

Special concerns

Where did you hear about this website?

The Law Office of Robert E. McRorey
108 E Cedar, Olathe, KS 66061
P.O. Box 61, Olathe, KS 66051-0061
Toll Free: (866) 237-0932
Phone: (913) 440-0603
Fax: (913) 339-9013
Email: remcrorey@yahoo.com