Are you presently married.

Yes

Are you currently living together or Separated?

No

Is your spouse planning to file bankruptcy with you?

Yes

No

Do you have any children under the age of 18 who live with you presently.

Yes

How many children do you have?

No

Financial Information

Sometimes its urgent to file a bankruptcy. Do any of these apply to you?

Facing foreclosure and I have a sale date very soon.I have been notified that my wages are about to be garnished.I'm behind on car payments and they are going to repossess my car.All my money was taken out of my bank account. My bank account has been levied.I'm being sued!I owe child support and my license is being affected.I'm constantly being harassed by creditors and phone calls and I CAN'T TAKE IT ANYMORE!

Please check all of the types of debts that you think you have:

Home Loan(s)Car Payment(s)I owe taxes.I guaranteed a loan for a family member or friend.I have business loan(s).Home Owners Association DuesPay Day Loan(s)Personal Loan(s)Title Loan(s)Credit Card Debt

Income Information

Are you presently Employed?

Yes

How much money do you make Gross per month.

No

What is your present source of income? How much are you receiving each month.

If you are married and not separated, if your spouse is employed, how much does your spouse earn per month

Yes

How much gross does your wife make.

No

If you are not employed, what is the source of your income? Check all that apply.

If applicable, spouse is working.I am self-employed and own a business.I receive Social Security, Disability or a Pension.I receive child support/alimony.My family is supporting me.

Our firm offers discounts to various members of our community. Please check if any of these apply to you.

I am a military veteran.I am a first responder.I am a teacher.I am a nurse.I am a senior citizen.I am disabled.I live in Chatsworth, California.

Is there anything else going on that has you thinking about bankruptcy?

This Form is exclusively for the use of the Law Offices of R. Grace Rodriguez, not for use by any third party, and is exclusively to help your attorney advise you on your bankruptcy options. By submitting this form, you certify that the information contained is true and accurate to the best of your knowledge. If this is correct, please indicate the date below and submit this form to our office per the instructions.