Questionnaire #1 - Basics & Income

Please complete your personal Bankruptcy Questionnaire for Information and free consultation about your individual circumstances and unique situation.

This information is input into our bankruptcy program which will result in a print out for the court if you should decide to file. It puts all the information in the order I review it. By using this, you can see a financial overview of your particular circumstances at no charge to you.

With this evaluation in your hands, you are able to use the overall information to BEGIN your best financial route even if you decide bankruptcy is not your best route.

Questionnaire 1 - Voluntary Petition & Means Test

How did you hear about us?

	Friends and Family
	Internet Search
	Craigslist Advertisement
	Penny Saver Advertisement

Did you filed bk in the past eight yrs?

	YES
	NO

If yes, what year?

If yes, what city, state and when

If yes, what is the case number?

E-mail Address*

Preference for the court fees?

	PAY IN FULL $335
	IN PAYMENTS
	WILL REQUEST A FEE WAIVER

Do you have a counseling certificate complete?

	NO, what is it?
	NO, I know what it is. https://www.debtorcc.org/
	YES, I have one.

Your Full Name (please include middle)*

All other names you have used in the last 8 years Include your married or maiden names.

Last 4 of social ONLY (not full social)

Any business names and Employer Identification Numbers (EIN) you have used in the last 8 years Include trade names and doing business as names

Physical Street Address*

City, State *

Your zip code*

Mailing Address including zip - if different

What county do you live in? *

Have you lived in this area for 181+ days

Best Phone

Chapter of Bankruptcy

	Chapter 7
	Chapter 11
	Chapter 12
	Chapter 13

Do you rent? Has your landlord obtained an eviction judgment against you?

	No. I don't rent.
	Yes. I rent and NO judgment.
	Yes. I rent and I have an eviction judgment.

Debtor's Employer Name (or enter "none" and skip related questions)

Debtor's Employer Address, City and Zip

Unemployment, if any $

Social Security, if any $

Government Assistance (Describe and $)

Family support payments that you, a non-filing spouse, or a dependent regularly receive Include alimony, spousal support, child support, maintenance, divorce settlement, and property settlement. $

Pension or Retirement $

Debtor's Occupation

When did you start this job?

Gross Wages Monthly $*

Overtime $

Tax, Medicare, and Social Security deductions

Mandatory contributions for retirement plans

Voluntary contributions for retirement plans

Required repayments of retirement fund loans $

Your insurance withheld monthly $

Domestic support obligations $

Other withholdings amount & description $

Union dues $

List any other source of income & $

If you are including expenses paid by others please list their name & the gift income from them

Expected 10 % change in income/expense in the 12 mths?

	YES
	NO

If yes, please explain the change

First Name, Age, Relationship of Dependents

MARRIED/SINGLE*

Spouse's full name, if married

List any other first, middle or last name used in the past 8 years

Last 4 of social ONLY (not full social)

Spouse's physical address - if different

Spouse's mailing address, if different

Unemployment, if any $

Social Security, if any $

Government Assistance, if any - Type & $

Family Support, if any $

Pension or Retirement $

Spouse's Occupation

When did your spouse start this job?

If any, Spouse's Employer Employer Name (or enter "none" and skip related questions)

Spouse's Employer's Address, City, State, Zip

Gross Wages Monthly $

Overtime $

Tax, Medicare, and Social Security deductions

. Mandatory contributions for retirement plans

Voluntary contributions for retirement plans

d. Required repayments of retirement fund loans

Spouse's insurance withheld monthly

Domestic support obligations

Spouse's union dues monthly

Spouse's other withholdings amount and description

List any other source of income & amount

Do you expect a 10% change in income in the next 12 months?

	YES
	NO

What do you expect to change? Note if spouse if so.

Anything else you would like to say about income

PLEASE HIT SUBMIT

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Rica Gilmore, 757-932-RICA, VA #0225235314 GA #401322

Lance Mason, 478-744-1257 GA Real Estate Agent #428771

Sean Gilmore, VA Real Estate Agent #0225246258

Laurinda Mason, Project Manager and Transaction Coordinator

FIRM - Rica Realty VA #0226034555

FIRM - Rica Gilmore Realty GA #81053

144 Shoe Lane, Newport News, VA 23606 - 1 (757) 932-RICA

Current Affiliates Business Arrangements and Family Businesses

Rica Gilmore is a Morty Loan Originator

NMLS ID# 2549170 Morty's NMLS ID# 1429243

Rica Realty is a family business and agents are related.

This website contains information related to law and is NOT LEGAL advice. It contents is for information only. If you need legal advice, please consult an attorney or act as your own.