Case Evaluation

Bold labels and indicate required information.

Name

E-mail Address

Phone

Do you intend to file a joint bankruptcy petition?

Yes

No

If yes, include information for both yourself and your spouse below:
Name(s), including middle initial

Residence address, including county

How long have you been at this address?

How Long	Address

Other telephone number(s)

Work

Cell

Other

Have you used any other name(s) in the last six years?

Yes

No

If yes, please list here

Single

Separated

Married

Divorced

If married, how long?

If divorced, how long?

Ages of minor children living with you

Ages, and amount of child support paid:

Age	Amount
	$
	$
	$
	$

Is any child support past due?

Yes

No

Amount

Husband's employment:

How long at this job?

Occupation

Income paid

Single

Separated

Married

Divorced

Gross

Net

Wife's employment(name and addr.):

How long at this job?

Income paid

Single

Separated

Married

Divorced

Gross

Net

Income from other sources (second job, investments, social security, child support, worker's compensation, etc.) (state sources and amount):

Do you owe any money to the Internal Revenue Service?

Yes

No

If yes, for what year(s)?

How much?

$

Do you have any unpaid student loans?

Yes

No

Amount

$

Monthly Expenses Real Estate Taxes

Rent		Real Estate Taxes
Electric		Home Maintenance
Gas		Life Insurance
Water		Health Insurance
Phone		Auto Insurance
Cable		Homeowner/Rent Ins.
Trash		House Payment

Do you pay anyone spousal support (alimony)

Yes

No

If yes, to whom and how much?

$

Do you own or are you purchasing a home or other real property?

Yes

No

Tax Assessed Value

$

First Mortgage Loan Balance

$

Loan Current?

$

Amount Behind

$

2nd Mortgage Loan Balance

$

Loan Current?

$

Amount Behind

$

3rd Mortgage Loan Balance

$

Loan Current?

$

Amount Behind

$

Are you facing foreclosure?

Yes

No

Foreclosure Date

$

List any liens against your property

$

List all vehicle loans (car, truck, motorcycles; identify vehicle type)

   

Vehicle	Est. Loan Balance	Loan Current	Amount Behind

List all vehicles you own outright (no loan balance)  

Vehicle	Est. Value

Foreclosure Date

$

Have you purchased any secured items (electronics, boats, jet ski, appliances, etc.) in the last two years on which you still owe money?

Yes

No

Have you taken out a loan from a finance company, credit union, bank or any other place and secured the loan by household items or other type of secured collateral?

Yes

No

Creditors' Names

$

Estimate balances owed on all other types of debt listed below

	Medical Bills
	NSF Checks
	Credit Cards
	Misc. Bills

When was the last time you used any of your credit cards? (approx. date)

$

How much has total owed on cards gone up in the last 12 months?

$

Have you had any new cards issued in the last 12 months?

$

Do you anticipate receiving a tax refund?

Yes

No

How much?

$

Are you eligible for the Earned Income Credit?

Yes

No

How much?

$

List all judgments, lawsuits, liens, and garnishments against you.

Special concerns

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Espy, Metcalf & Espy, P.C.
326 North Oates Street
Dothan, AL 36303
Phone: 334-793-6288
Toll Free: 866-840-5397
Fax: 334-712-1617
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Espy, Metcalf & Espy, P.C., represents residents of Dothan and other communities such as Enterprise, Troy, Ozark, Eufaula, Opp, Andalusia, Montgomery, Phenix City, Auburn, Opelika, Brundidge, Fort Rucker, Geneva, Houston County, Geneva County, Henry County, Dale County, Coffee County, Barbour County and Pike County, Alabama.

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