Name: ". $_SESSION['fname'] ." ". $_SESSION['lname']; $msg .= " (Click to view detailed record.)"; $msg .= "
Contact: ". $_SESSION['email'] .""; $msg .= "
Phone: ". $_SESSION['p_ac'] . $_SESSION['p_prefix'] . $_SESSION['p_ext']; $msg .= "

Reason for considering bankruptcy:
". $_SESSION['reason']; send_message("dhillier@gumandhillier.com","[Gum and Hillier] New Contact Information",$msg); //dhillier@gumandhillier.com ?> Thank you for filling out out contact form. Someone will look over your information and be in contact shortly.
1. Personal
First Name
'>		Last Name
'>
Spouse's First Name
'>		Spouse's Last Name
'>
Address
'>
City
'>		 State
'>		 Zip
'>
Phone Number
'> '>-'>		 Fax Number
'> '>-'f_ext>
Email Address
'>

     
2. Considerations Please briefly explain your reasons for wanting to file bankruptcy.

     
3. Assets Cars
Year
'>		 Make
'>		 Model
'>		 Mileage
'>		 Est. Value
'>		 Amt. Owed
'>
'> '> '> '> '> '>

Real Estate
Value
'>		 Amt. Owed
'>		 Description (Type, acreage, etc.)
'> '>

Personal Property
Any other property of value (bank accounts, stocks, antiques, retirement accounts, tax refunds, machinery and equipment, jewelry, collectibles)
Value
'>		 Amt. Owed
'>		 Description
'>
'> '> '>
'> '> '>

     
4. Creditors List all, even for things you want to keep (even small accounts)
Name
'>		Account #
'>
Address
'>
City
'>		 State
'>		 Zip
'>
Amt. Owed
'>
Name
'>		Account #
'>
Address
'>
City
'>		 State
'>		 Zip
'>
Amt. Owed
'>
Name
'>		Account #
'>
Address
'>
City
'>		 State
'>		 Zip
'>
Amt. Owed
'>

     
5. Employment Information Employer
Employer
'>
Address
'>
City
'>		 State
'>		 Zip
'>

Pay Period

Pay
Gross Pay
$'>		 Net Pay
$'>		 Year to Date
$'>

     
6. Budget Monthly Budget, showing average monthly household expenses.
Rent or House Payment:$'> Laundry/Cleaning:$'>
Electric:$'> Medical/Dental:$'>
Heat:$'> Transportation:$'>
Water:$'> Sewage:$'>
Entertainment:$'> Cable:$'>
Child Support:$'> Telephone:$'>
Car Payments:$'> Food:$'>
Charity:$'> Clothing:$'>
Insurance (that you pay):$'>

     
7. Tax Returns (For a filing, provide and tax return information.
Adjusted Gross Income
Current
$'>		 Last Year
$'>		 Previous
$'>

     

Bankruptcy Questionnaire:

The decision to file for bankruptcy is a big step. Let us help you make the most informed decision possible. On the pages following this one, you will be asked to provide a good deal of information about your current financial status. Please take your time and provide the most accurate information possible. If you'd like, print the pages, accumulate the information and come back to our site to fill out the form. Your information is strictly confidential.