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Name ,
Marital Status Choose One Single Married Divorced Separated
If married, what is spouse's name
,
If married, do you plan to file bankruptcy as an individual, or jointly with your spouse?
Individual Jointly Not Sure Choose One (if married)
How many people are in your household that you must support?
(include yourself & your spouse)
Address , AK AZ CA CO CT DE GA HI IL ID KY LO LI MO MS NC ND NJ NM NY OH RI TN TX UT WV WA WY
If you live in Colorado, what county do you reside in?
County Choose One Adams Alamosa Arapahoe Archuleta Baca Bent Boulder Broomfield Chaffee Cheyenne Clear Creek Conejos Costilla Crowley Custer Delta Denver Dolores Douglas Eagle Elbert El Paso Fremont Garfield Gilpin Grand Gunnison Hinsdale Huerfano Jackson Jefferson Kiowa Kit Carson Lake La Plata Larimer Las Animas Lincoln Logan Mesa Mineral Moffat Montezuma Montrose Morgan Otero Ouray Park Phillips Pitkin Prowers Pueblo Rio Blanco Rio Grande Routt Saguache San Juan San Miguel Sedgwick Summit Teller Washington Weld Yuma
Home Phone Work Phone
Cell Phone E-Mail
Where did you hear about us?
Questdex Yellow Book/McLeod Colorado Daily Westword Internet Other Choose One
How much debt do you have not counting vehicles or mortgages?
$
How many creditors do you believe that you have?
If you have credit card debt, when was the last time you charged?
What is your monthly household net income (after taxes, take home income)?
(Include spouse's income even if you intend to file individually)
You $ Spouse $
Do you own any vehicles? YES NO
If you answered "YES" above complete the following information:
Vehicle 1 , ,
Fair Market Value $ Balance Owed $
Monthly Payment $
What are your intentions with this vehicle? Keep Vehicle Surrender Vehicle Choose One
Vehicle 2 , ,
Vehicle 3 , ,
Do you own any real estate? YES NO
What are your intentions with this real estate? Keep Home Surrender Home Choose One
Purchase Date Purchase Price $
Have you refinanced in the last two years? YES NO
How many mortgages do you have on your property?
How much is owed on each mortgage?
First Mortgage $ Second Mortgage $
Third Mortgage $
What do you think you could sell the home for if you wanted to?
Have you sold or transferred any real estate in the last four years?
YES NO
Describe any other assets you own that have significant value
Description
Approx. Value $
Taxes
What did you show for taxable income on your most recent tax return (AGI)?
Do you owe the IRS or state for back taxes?
Are there any years for which you have not filed state or federal income tax returns?
If yes, what years?
Did you get a tax refund last year?
If yes, how much? $
Have you ever filed bankruptcy before? YES NO
If yes, what year? what chapter Chapter 7 Chapter 13
In the last two years have you given or paid more than $500 to any friend or relative?
Does anyone owe you any money? YES NO Amount $
Have creditors been calling you at home or work?
(Home) YES NO (Work) YES NO
Have you been served with a summons in the last year?
Have you been involved in a law suit in the last year? YES NO
If you answered yes above, please give brief description on the law suit:
Are your wages being garnished? YES NO
Are you behind on your home and/or car payment? YES NO
Will you have trouble obtaining the address of any of your creditors?
Do you own a business? YES NO
If yes, please give brief description of business:
Is there any additional information that may be relevant to your case?
Are there any questions that you need an answer for right now?
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Colorado Bankruptcy Form
