The Law Offices of Ed L. Laughlin

Waco Office	Temple Office	Killeen Office
427 N 38th St. Waco TX 76710 254-714-2500 888-711-2507	1509 W Ave J Temple TX 76504 254-773-8399 800-492-2589	1101 E Central TX Expwy Killeen TX 76541 254-699-2460 888-663-2460

Instructions for filling out this form:

Read each question carefully.
Fill out the form completely.
Review the form for accuracy.
Once you have completed this form, click the 'Submit Form' button at the bottom of the page.

Bankruptcy Initial Interview

Survey:

How did you hear about us?

Personal Information:

Dependents:

List the total number of dependants in your family, including yourself that you claimed on your income taxes last year.

Name	Relationship

Financial Questions:

Do you own a home?	Yes No
Are you renting?	Yes No
Are you behind on your house payments?	Yes No
Do you owe the IRS?	Yes No
Do you owe real estate taxes on your home?	Yes No
Do you owe any student loans?	Yes No
Are you behind on child support?	Yes No
Are your wages being garnished now or are they about to be garnished?	Yes No
Do you have any judgments against you?	Yes No
Are you currently involved in any lawsuits, personal injury suits, social security claims or any other action that you may be entitled to a cash settlement?	Yes No
Have you made any credit card purchases, cash advances, or loans in the past 2 months?	Yes No
Have you sold any property, transferred any property or given any large gifts within the past year?	Yes No
Did you receive an income tax refund last year?	Yes No
If Yes, how much was your refund check?	$
What month did you receive it in?
Have you made any withdrawals from any financial institutions in the past 6 months?	Yes No
If Yes, how much?	$
Have you filed bankruptcy before?	Yes No
If Yes, when and where?

Accounts:

If you have any stocks, bonds, money market accounts, annuities, CD's, 401K Plans, IRA's, etc.,
list the account type and amount.

Account Type	Amount
	$
	$
	$
	$
	$
	$
	$
	$
	$
	$

Property:

List any homes, land or funeral plots that you may have. (This includes any property that you may have inherited.)

Property Address (Street Address, City, State, Zip)	Monthly Payment
	$
	$
	$
	$
	$
	$
	$
	$
	$
	$

Vehicles:

List all vehicles you own including those that are paid off.

Vehicle (Year, Make, Model)	Monthly Payment
	$
	$
	$
	$
	$
	$
	$
	$
	$
	$

Secured Debts:

List all Secured debts you owe for a boat, motorcycle, trailer, furniture, appliances, electronics, motor homes, recreational vehicles, jet ski, etc?

Description	Monthly Payment
	$
	$
	$
	$
	$
	$
	$
	$
	$
	$

Unsecured Debts:

List all of your Unsecured debts.
(Examples: medical debts, credit cards, charge accounts, personal loans, bad check fees and auto accidents)

Please estimate the amount you owe for each debt if you do not know the exact amount(s).

Debt	Amount Owed
	$
	$
	$
	$
	$
	$
	$
	$
	$
	$
	$
	$
	$
	$
	$
	$
	$
	$
	$
	$

Income Sources:

List any other income from ALL other sources (not already listed) that you have received in the past 6 months, including but not limited to any type of disability, retirement benefits, 401K withdrawals or loans, inheritance, stocks, bonds, food stamps, any other type of government assistance, etc.

Income Type	Amount
	$
	$
	$
	$
	$
	$
	$
	$
	$
	$

Approximate Income and Expenses (rounded to the nearest dollar):

INCOME
Your total monthly GROSS (before taxes) income	$
Your spouses monthly GROSS (before taxes) income	$
Other monthly GROSS (before taxes) income	$
TOTAL MONTHLY INCOME	$

ESTIMATED FUTURE MONTHLY EXPENSES
Rent/House Payment	$
Utilities - Electric	$
Utilities - Gas	$
Utilities - Water	$
Utilities - Home Phone	$
Second Lien on your home	$
Home Maintenance	$
Cellular Phone	$
Cable	$
Internet	$
Home Security Systems	$
Vehicle Security Systems	$
Laundry & Dry Cleaning	$
Food & General Household Expenses	$
Lunches (School/Work)	$
Family Clothing/Grooming (include haircuts, etc.)	$
Reading Material (include school books)	$
Medical/Dental (include all medications)	$
Optometry Expenses (include glasses, etc.)	$
Child Support/Alimony (not deducted from paycheck)	$
Day Care/After School Child Care	$
Work related expenses (include tools, etc.)	$
1st Auto Payment	$
2nd Auto Payment	$
3rd Auto Payment	$
Auto Insurance	$
Auto Operating Expenses (includes gas, oil, etc.)	$
Other Insurance not deducted from paycheck	$
Expenses for Child(ren) (include activities)	$
Expenses for College	$
Hobbies (bowling, bingo, racing, crafts, etc.)	$
Club Memberships (athletic, auto, etc.)	$
Use of Tobacco Products (any type)	$
Pet Expenses (vet and food)	$
Charitable Contributions (church, etc.)	$
Expenses not listed (explain in Comments Section)	$
TOTAL MONTHLY EXPENSE	$

TOTAL GROSS MONTHLY INCOME AFTER EXPENSES	$

Type Comments Here...