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1. Your Name:
2. Address:
3. Telephone number:(daytime) (evening)
4. Where do you work?
5. What is your take home pay?How often are you paid?
6. Check one: Married Divorced Separated Single Widowed
YOUR SPOUSE:
7. What is your spouse's name:
8. Where does your spouse work?
9. What is his/her take home pay?How often is he/she paid?
10. Please give us the following information on any cars,
trucks, boats, campers, motorcycles or trailers you presently
have in your possession and indicate the year, make and model
of each:
Vehicle Lien holder Approximate pay off Monthly Current balance
payment value
11. How were you referred to this office?
If you were referred by yellow pages, select which one
12. If you have a Mortgage or Land Contract on your home,
please indicate below the name and address of the Mortgage/Land
Contract holder, the approximate balance owing, the monthly payment
and whether or not your payment includes tax or insurance escrows:MortgageLand
Contract
Name and address of Mortgage/Land Contract holder:
Approx. balance: $Monthly payment $Escrows? yesno
Is the escrow just for real estate taxes or also for insurance?
Are your payments current? YesIf no, how many payments are behind?
13. Is there a second mortgage or any other debt on the property?YesNo
If so what is the name of the mortgage holder?
Approx. balance of second mortgage:$Monthly payment:$
Are your second mortgage payments current?YesIf no, how many payments
are behind?
14. How long ago did you purchase the property?
15. What was the original purchase price? $
and what is the current State Equalized Value? $
Please bring a complete list of who
you owe and how much to your first appointment.
Thank you for taking the time to complete this initial questionnaire.
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