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Is Bankruptcy the Right Option for Me?

Complete This Confidential, No Obligation Evaluation

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*Last Name:
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Street Address:
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Debt

Please Approximate Amounts Currently Owed

Mortgage or Rent
 $0 Under $1,000 $1,000-$10,000 $10,000-$20,000 $20,000-$50,000 Over $50,000
Personal Loans
 $0 Under $1,000 $1,000-$10,000 $10,000-$20,000 $20,000-$50,000 Over $50,000
Credit Card Debt
 $0 Under $1,000 $1,000-$10,000 $10,000-$20,000 $20,000-$50,000 Over $50,000
Student Loans
 $0 Under $1,000 $1,000-$10,000 $10,000-$20,000 $20,000-$50,000 Over $50,000
Medical Bills
 $0 Under $1,000 $1,000-$10,000 $10,000-$20,000 $20,000-$50,000 Over $50,000
Tax Debts and Fines
 $0 Under $1,000 $1,000-$10,000 $10,000-$20,000 $20,000-$50,000 Over $50,000
Legal Judgments (including child support)
 $0 Under $1,000 $1,000-$10,000 $10,000-$20,000 $20,000-$50,000 Over $50,000
Briefly describe your main concerns: for example, foreclosure, garnishment, car repossession, suit, harassment.
What threats, if any, have been made?

Income and Assets

Employment Status
 Employed Full Time Employed Part Time  Self-employed  Unemployed
Current Annual Income
Other income sources: (Check all that Apply)
 Disability Child Support Social Security Unemployment Pension Worker's Compensation Rental Income
Do you own real estate?
 Yes No
Are your mortgage payments up to date?
 Yes No
Do you own a vehicle?
 Yes No
Are your payments up to date?
 Yes No Not Applicable

Disclaimer Text: By completing this form, you agree that a representative from O'Connor, Acciani and Levy may contact you. This contact form does not determine qualification for personal bankruptcy and should not substitute for qualified legal advice. Data supplied on this form will be used confidentially by O'Connor, Acciani and Levy for purely internal purposes and will not be sold, transferred or publicized in any way.

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