SSN# (Optional) 

City

State

Zip Code

Work/Cell Phone

Bold = Required field

Spouse Name

SSN# (Optional)

Address Line 1

What County Do You Live In?

How Long?

How Long Have You Lived In CA?

If Less Than 2 Years, What State Did You Live In Previously?

Do You Own Any Vehicle(s)?

Are You Behind In Payments?

Year

Mo. Payments $

Model

Year

Mo. Payments $

Model

Make

Make

Year

Make

Model

Mo. Payments $

Do You Have Any Credit Card Debt?

If So, Approximately How Much?

When Was The Last Time You Used Your Credit Card?

Have You Filed For Bankruptcy Before?

If So, When?

What Chapter?

Do You Own A House?

Are You Behind In Payments?

Do You Have Any Liens On Your Home?

If So, When?

Have You Owned Any Real Property In The Past 10 Years?

Do You Have Any Judgments Pending?

Do You Owe Any Back Child Support Or Alimony?

If So, How Much?

If So, When?

Do You Owe The IRS?

If So, How Much?

Year(s)

Franchise Tax Board?

If So, How Much?

Year(s)

Do You Have A Student Loan?

If So, How Much?

Monthly Take Home Income For You              $

Spouse             $

Yellow Pages (Sacramento/Roseville)

Friend or Referral

Internet

Name

Completing this form will help us to get a better idea as to where you stand and what action you should take. Please fill it out and give us a call to schedule a free consultation. 916-641-1000.

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