Debt Relief Questionnaire | Blake Goodman, PC

Questionnaire - New

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Have you made an appointment with our office yet?*
If yes, on which day did you schedule your appointment?
First Name*
Last Name*
Spouse's First Name
Spouse's Last Name
Street Address*
City*
Zip Code
Phone*
Work Phone*
Email*
Employer
Employer, Position
Spouse's Employer, Position
Questionnaire
How did you hear about us?
How long have your lived at your current address?
What is your marital status?
Do you have any children under the roof with you or are other wise dependents?
If yes, how many and what are their ages?
Do you own any real estate?*
Do you own any burial plots/plans or timeshares?
Do you own any vehicles?
Do you own or operate a business?
Do you have any of the following property?
- Savings Account
- Stocks, Bounds, Investments
- Retirement Account
Have you ever filed Bankruptcy before?
Are you suing anybody or is anybody suing you?
Could you sue anybody?
Income What is your approximate take home net income per month (not per pay period) after deductions for taxes, social security, and insurance? (Please include spouse's net income whether filing a case with you or not)
Your First Job Net Income Per Month
Your Spouse's First Job Net Income Per Month
Your Second Job Net Income Per Month
Your Spouse's Second Job Net Income Per Month
Your Business Net Income Per Month
Your Spouse's Business Net Income Per Month
Your Food Stamp Amount Per Month
Your Spouse's Food Stamp Amount Per Month
Your Child Support Per Month
Your Spouse's Child Support Per Month
Your Retirement Net Income Per Month
Your Spouse's Retirement Net Income Per Month
Other Sources
Your Other Sources of Net Income Per Month
Your Spouse's Other Net Income Per Month
Special Deductions
Are there any special deductions out of your pay?
You
Your Monthly Retirement Contribution?
Your Monthly Repayments On Loans To Employer?
Your Spouse
Your Spouse's Monthly Retirement Contribution?
Your Spouse's Monthly Repayments On Loans To Employer?

Expenses What are your approximate expenses per month for the following items?
Mortgage/Rent
Second Mortgage
Third Mortgage
Maintenence Fee
Out of Pocket Medical Expenses
Electricity
Laundry
Water
Haircuts
Gas
Cable
CableTelephone
Clothing
Car Payment
Car Insurance
Child Support
Food
Child Care
Charitable Giving
Life Insurance
Any Other Expenses (Ex: Diapers, Dog Food, Cigarettes)
Mortgages and Other House Related Debts
Mortgage 1: Name of Creditor
Mortgage 1: Balance (Best Guess)
Mortgage 1: Value of Real Estate
Mortgage 2: Name of Creditor
Mortgage 2: Balance (Best Guess)
Mortgage 2: Value of Real Estate
Mortgage 3: Name of Creditor
Mortgage 3: Balance (Best Guess)
Mortgage 3: Value of Real Estate
If more, please add to general comments.
Car Debts
Car Debt 1: Name of Creditor
Car Debt 1: Balance (Best Guess)
Car Debt 1: Year and Type of Car
Car Debt 2: Name of Creditor
Car Debt 2: Balance (Best Guess)
Car Debt 2: Year and Type of Car
Car Debt 3: Name of Creditor
Car Debt 3: Balance (Best Guess)
Car Debt 3: Year and Type of Car
If more, please add to general comments.
Credit Cards
Credit Card 1: Name of Creditor
Credit Card 1: Balance (Best Guess)
Credit Card 2: Name of Creditor
Credit Card 2: Balance (Best Guess)
Credit Card 3: Name of Creditor
Credit Card 3: Balance (Best Guess)
Credit Card 4: Name of Creditor
Credit Card 4: Balance (Best Guess)
Credit Card 5: Name of Creditor
Credit Card 5: Balance (Best Guess)
Credit Card 6: Name of Creditor
Credit Card 6: Balance (Best Guess)
If more, please add to general comments.
Signature Loans With Collateral
Signature Loan with Collateral 1: Name of Creditor
Signature Loan with Collateral 1: Balance (Best Guess)
Signature Loan with Collateral 2: Name of Creditor
Signature Loan with Collateral 2: Balance (Best Guess)
Signature Loan with Collateral 3: Name of Creditor
Signature Loan with Collateral 3: Balance (Best Guess)
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Untitled
If more, please add to general comments.
Signature Loans Without Collateral
Signature Loan without Collateral 1: Name of Creditor
Signature Loan with Collateral 1: Balance (Best Guess)
Signature Loan without Collateral 2: Name of Creditor
Signature Loan with Collateral 2: Balance (Best Guess)
Signature Loan without Collateral 3: Name of Creditor
Signature Loan with Collateral 3: Balance (Best Guess)
If more, please add to general comments.
Medical Bills
Medical Bill 1: Name of Creditor
Medical Bill 1: Balance (Best Guess)
Medical Bill 2: Name of Creditor
Medical Bill 2: Balance (Best Guess)
Medical Bill 3: Name of Creditor
Medical Bill 3: Balance (Best Guess)
If more, please add to general comments.
Student Loans
Student Loan 1: Name of Creditor
Student Loan 1: Balance (Best Guess)
Student Loan 2: Name of Creditor
Student Loan 2: Balance (Best Guess)
Student Loan 3: Name of Creditor
Student Loan 3: Balance (Best Guess)
If more, please add to general comments.
Loans to Family and Friends
Loan to Family / Friend 1: Name of Creditor
Loan to Family / Friend 1: Balance (Best Guess)
Loan to Family / Friend 2: Name of Creditor
Loan to Family / Friend 2: Balance (Best Guess)
Loan to Family / Friend 3: Name of Creditor
Loan to Family / Friend 3: Balance (Best Guess)
If more, please add to general comments.
Others
Name of Other Creditor #1
Other Balance 1 (Best Guess)
Name of Other Creditor #2
Other Balance 2 (Best Guess)
Name of Other Creditor #3
Other Balance 3 (Best Guess)
If more, please add to general comments.
Back Tax Debt
Back Tax Debt 1: Name of Creditor
Back Tax Debt 1: Type of Tax
Back Tax Debt 1: Year
Back Tax Debt 1: Balance (Best Guess)
Back Tax Debt 2: Name of Creditor
Back Tax Debt 2: Type of Tax
Back Tax Debt 2: Year
Back Tax Debt 2: Balance (Best Guess)
Back Tax Debt 3: Name of Creditor
Back Tax Debt 3: Type of Tax
Back Tax Debt 3: Year
Back Tax Debt 3: Balance (Best Guess)
If more, please add to general comments.
General Comments
Message

I was very pleased with the outstanding service.

"I was very pleased with the outstanding service you provided. You and your staff consistently made extra efforts in assisting me with my bankruptcy case. I will definitely recommend your business to others because of my satisfaction with your service."
Phetsamone Vuong
Mr. Goodman and his staff were great.

"Mr. Goodman and his staff were great and worked with me every step of the way."
Randi Brown
Responsive, knowledgeable, and very thorough.

"Blake Goodman provided professional and outstanding legal advice. They are responsive, knowledgeable, and very thorough. I would recommend his firm with complete confidence knowing that they will receive the best possible service."
Moune Romano
I’m very grateful to Mr. Goodman.

I’m very grateful to Mr. Goodman for the effort and patience he had with me and my daughter. I appreciate it. As for his staff members, they are very kind. My grand-daughter reports to me that Mr. Blake Goodman is a very highly honored attorney.
Martha Aki
Everything is possible with you. Thanks on a job well done!

I am very pleased with your services and would wholly recommend your excellence to everyone. I am happy with the outcome of my case. Everything is possible with you. Thanks on a job well done!
Randy Borges
Mr. Goodman and his staff are so nice and personable.

When I first came to Mr. Goodman’s office, I was prepared to file bankruptcy – I was tens of thousands of dollars in debt and could see no way out. He helped me work out a payment plan then negotiated with my creditors on my behalf...
Steve