JEFFREY S. POSIN, ESQ.

*ALSO MEMBER OF ARIZONA BAR

INFORMATION SHEET

Today’s Date_________________
*Use "TAB" key to navagate through fields. Hover mouse over field for tips on proper format of information on dates and numbers.
*When form is complete, you can print it, bring it to your appointment and save time!

A. PERSONAL INFORMATION

Mr. Mrs. Ms. ____________________________ Your Social Security No. ______________________ Date of Birth ____________

Spouse _________________________________ Spouse’s Soc. Sec. No. _______________________ Date of Birth ____________

Address ________________________________ City ____________________________________ State _____ Zip ___________

County _________________________________ Home Phone ___________________________ Cell Phone __________________

E-Mail Address ______________________________________

Dependents? Name & Age _____________________________________________________________________________________

How did you hear about our firm? _______________________________________________________________________________

Do you know any individual(s) that our firm is representing or has represented?_______ If yes, who? _________________________

Marital Status __________

Name of your Employer __________________________________ How long? ________ Work Phone No ______________

Your Occupation __________________________________________

Name of Spouse’s Employer ______________________________ How long? _________ Work Phone No ______________

Spouse’s Occupation _______________________________________

(Please choose a response for the following questions)

Do you: ______ your home Are you behind in house or rent payments? _______ How Many? ___________

Do you owe IRS or STATE taxes? _______ How much to IRS $ _______________ State $ ____________________

Do you owe student loans? _______ If yes, how many student loans? _____ How much $______________

Are you behind in child support? _______ How much $ _____________

Are you behind in spousal support? _______ How much $_____________

Have you had any credit card cash advances in the last six (6) months? _______

Do you have any NSF/Bounced Checks outstanding? _______

If yes, have they been turned over to the District Attorney? _______

If yes, have they been turned over to a collection agency? _______

Have you been threatened with criminal prosecution for any debt? _______

Are you in the military?

Are your wages being garnished or about to be garnished? _______

Do you have any pending lawsuits against you? ________

Do you have any outstanding judgments against you? _______

Are you suing anyone? (car accident, SS disability claim, workers comp, class action lawsuit, etc.) _______

Have you co-signed for a loan for anybody? _______

Do you have any rent-to own contracts, pawns, or check advance loans? _______

Have you sold or transferred any property within the last two (2) years? _______

Do you have any 401K, IRA, thrift savings or retirement plans? _______

Do you have any Stocks, investments or e-trade accounts? _______

Have you ever filed Chapter 7 Bankruptcy or Chapter 13 debt consolidation? _______

If yes, what year? _______ Chapter _______

B. SECURED DEBTS

HOME LOANS: _______ Property Address: _________________________________________________________

1st MTG Payments $__________/month Payoff Amount $___________________ Behind? _______

If yes, how many months _______

2nd MTG Payment? $_________/month Payoff Amount $____________________ Behind? _______

If yes, how many months _______

3rd MTG Payment? $________/month Payoff Amount $____________________ Behind? _______

Approximate Value of Property $______________________ Year Purchased _______ Purchase Price $_______________

SECOND HOME: _______ Property Address: ____________________________________________________________

1st MTG Payment $__________/month Payoff Amount $___________________ Behind? _______

If yes, how many months _______

2nd MTG Payment $__________/month Payoff Amount $____________________ Behind? _______

If yes, how many months _________

3rd MTG Payment $__________/month Payoff Amount $____________________ Behind? _______

Approximate Value of Property $______________________ Year Purchased _________ Purchase Price $_______________

Are you buying a Mobile Home? _______ If Yes: Year _________ Make_______________ Model ___________________

Payment $ _______________ Balance Owed $ _______________

Do you own or rent land? ______________ Payment $_______________ Balance Owed $___________________
Do you own or have any ownership interest in any other real estate? _______

Have you received a letter from an attorney advising of a foreclosure sale date? _______ Sale Date ______________________

C. VEHICLES: _______

1stAuto:Yr/Make _________________________ Status ______________ Pymnt $ ____________ Balance $_______________

2ndAuto:Yr/Make _________________________ Status ______________Pymnt $ ___________ Balance $_______________

3rdAuto:Yr/Make _________________________ Status ______________ Pymnt $ ____________ Balance $_______________

4thAuto:Yr/Make _________________________ Status ______________ Pymnt $ ____________ Balance $_______________

Are you behind on any car payments? _______ How many? _______

Date of most recent vehicle purchased? __________

D. INCOME:

Income: YOUR TOTAL GROSS monthly income (before taxes) from employment? $_________________

SPOUSES TOTAL GROSS monthly income (before taxes) from employment? $_________________

Monthly income from child support/alimony $_________________

Monthly income from Retirement $_________________

Other monthly income from _____________________________ $_________________

TOTAL MONTHLY INCOME 0.00

$_________________

Your average income for the LAST SIX MONTHS $_______________/month

I get paid: _______________

My TAKE HOME pay per period is $ ________________

My LAST pay date was ___________________________ My NEXT pay date is __________________

My Spouse gets paid: _______________

My SPOUSE’S TAKE HOME pay per period is $ _______________

My SPOUSE’S LAST pay date was _______________________ My SPOUSE’S NEXT pay date is: __________

PLEASE FILL OUT THE FOLLOWING TWO PAGES TO THE BEST OF YOUR ABILITY. IF YOU
DON’T KNOW THE EXACT AMOUNTS PLEASE USE YOUR BEST ESTIMATE.
E. EXPENSES

Enter estimated average current monthly expenses for you and your spouse:

Rent, Mortgage, or Mobile Home payment $

Real estate taxes (if not included in payments) $
Property insurance (if not included in payments) $
Lot rent for mobile home (if applicable) $
Electricity and Gas $
Water and Sewer $
Telephone and Cell Phone $
Garbage $
Cable $
Security $
Other Utilities $
Home Maintenance $
Food $
Clothing $
Laundry & Dry Cleaning $
Medical, Dental, Medication (Out of pocket including co-pays) $
Transportation (Gas, oil, maintenance, taxi and bus fares, NOT including car payments) $
Recreation, Entertainment, etc. $
Charitable contributions (Not deducted from paycheck) $
Homeowners/Renters insurance (Not deducted from paycheck) $
Life insurance (Not deducted from paycheck) $
Health insurance (Not deducted from paycheck) $
Auto insurance (Not deducted from paycheck) $
Disability insurance (Not deducted from paycheck) $
Other insurance (Not deducted from paycheck) $
Taxes NOT deducted from wages or included in home payments $
Auto payments (Total all car payments) $
Expenses for operation of a business, profession, or farm $
Alimony, child support, and maintenance paid to others $
Care for elderly, chronically ill, or disabled family members $
Child care $
Other expenses $
$
$
$
TOTAL $ 0.00
F. DEBT:

Please list total estimated balances by CATEGORY (Not individual creditor). For example Credit Card
debt, Auto debt, Medical bills, etc.

TOTAL
CO-
BALANCE OWED
CATEGORY SIGNER
(If unknown (Y/N)
estimate)

TOTAL $ 0.00