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Have you filed bankruptcy in the last 8 years?

Yes No

Bills

What type of bills do you have? (check all that apply)

Credit Cards Home Mortgage Auto Loans
Medical Bills Student Loans Judgments
Income Taxes Court Fines Personal Loans

Do you own or are you buying a home?

Yes No

Are you behind on payments on your home?

Yes No

Do you own a car?

Yes No

Income

What is your gross (before any deductions) monthly income from all sources?
How many people live in your household?
Are you single or married?
Describe all other monthly income received by all members of your household.

Has your total monthly household income decreased by more than 10% in the last 6 months?

Yes No