Name*: Spouse:

Address:

City: State: Zip:

Home Phone*: Cell Phone:

Email:

What county do you live in? How Long?

How long have you lived in California?

If less than 2 years, what state did you live in before?

Vehicles

Do you own any vehicles? Yes No

Year Make Model Mo. Payment $

Year Make Model Mo. Payment $

Year Make Model Mo. Payment $

Credit Debt

Do you have any credit card debt? Yes No
If yes, approximately how much? $

Mortgage/Property

Do you own a home? Yes No

Are you behind on payments? Yes No

Do you have any liens on your home? Yes No
If yes, when?

Have you owned any real property in the past 10 years? Yes No

Legal

Have you ever filed for bankruptcy before? Yes No
If yes, when? What chapter?

Do you have any judgments pending? Yes No
If yes, when?

Do you owe any back child support or alimony? Yes No
If yes, how much? $

Taxes/Loans

Do you owe the IRS? Yes No
If yes, how much? $

Do you owe the Franchise Tax Board? Yes No
If yes, how much? $

Do you have any student loans? Yes No
If yes, how much? $

Do you have any other loans besides those listed already? Yes No
If yes, how much? $

Income

Monthly take home income
You: $ Spouse: $

Additional Information

Is there any other information you think we should know? Please explain briefly:

How did you hear about us?

Search Engine
Friend/Referral (Name: )
Yellow Pages
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