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h4k?@ABCDEFGHIJKLMNOPQRSTUVWXYZ[\]^_`abcdefghijklmnopqrstuvwxyz{|}~hicle (mo/yr):_____________ In whose name:___________________ Co-signers:___________________________________________ Is this a lease or a purchase:____________ When is loan/lease over?_______________ What is date of last payment?______________________ Copy of installment note?  please provide Vehicle 3  (year, make & model)__________________________________________________________ Finance/loan company:_________________________________ Acct #:__________________________ Address:_______________________________________________ Monthly payment: $______________ City:_________________ ST: __________ Zip:_____________ Total loan payoff: $________________ How many months behind are you?_______________ When did you buy vehicle (mo/yr):_____________ In whose name? ____________ Co-signers:_______________ Furniture Loans Furniture 1 (describe furniture):_________________________________________________________ Finance/loan company:________________________________ Acct #:__________________________ Address:____________________________________________ Monthly payment: $______________ City:_________________ ST: __________ Zip:____________ Total loan payoff: $_______________ In whose name:___________________ Co-signers:________________________________________ When was merchandise purchased:______________________ Do you still have it?________________ What is date of last payment?______________________ Copy of installment note?  please provide Do you want to surrender furniture and reduce or eliminate debt?______________________________ Furniture 2 (describe furniture):_________________________________________________________ Finance/loan company:________________________________ Acct #:__________________________ Address:____________________________________________ Monthly payment: $______________ City:_________________ ST: __________ Zip:____________ Total loan payoff: $_______________ In whose name:___________________ Co-signers:________________________________________ When was merchandise purchased:______________________ Do you still have it?________________ What is date of last payment?______________________ Copy of installment note?  please provide Do you want to surrender furniture and reduce or eliminate debt?______________________________ Furniture 3 (describe furniture):_________________________________________________________ Finance/loan company:________________________________ Acct #:__________________________ Address:____________________________________________ Monthly payment: $______________ City:_________________ ST: __________ Zip:____________ Total loan payoff: $_______________ In whose name:___________________ Co-signers:________________________________________ When was merchandise purchased:______________________ Do you still have it?________________ What is date of last payment?______________________ Copy of installment note?  please provide Do you want to surrender furniture and reduce or eliminate debt?______________________________ Finance Companies and Loan Companies Finance Company Loan 1 Did you pledge household goods (describe)______________________ Finance/loan company:_____________________________ Acct #:__________________________ Address:_________________________________________ Monthly payment: $______________ City:_________________ ST: ______ Zip:___________ Total loan payoff: $_______________ In whose name:___________________ Co-signers:_____________________________________ When did you take out loan:______________________ When is last payment due?___________ Keep or surrender? _________________ Copy of installment note  please provide_________ Finance Company Loan 2 Did you pledge household goods (describe)______________________ Finance/loan company:_____________________________ Acct #:__________________________ Address:_________________________________________ Monthly payment: $______________ City:_________________ ST: ______ Zip:___________ Total loan payoff: $_______________ In whose name:___________________ Co-signers:_____________________________________ When did you take out loan:______________________ When is last payment due?___________ Keep or surrender? _________________ Copy of installment note  please provide_________ Finance Company Loan 3 Did you pledge household goods (describe)______________________ Finance/loan company:_____________________________ Acct #:__________________________ Address:_________________________________________ Monthly payment: $______________ City:_________________ ST: ______ Zip:___________ Total loan payoff: $_______________ In whose name:___________________ Co-signers:_____________________________________ When did you take out loan:______________________ When is last payment due?___________ Keep or surrender? _________________ Copy of installment note  please provide_________ Loans for Jewelry, Gifts & Household Goods Secured Creditor 1 (Describe items purchased)_____________________________________ Finance/loan company:_____________________________ Acct #:__________________________ Address:_________________________________________ Monthly payment: $______________ City:_________________ ST: ______ Zip:___________ Total loan payoff: $_______________ In whose name:___________________ Co-signers:_____________________________________ When did you take out loan:______________________ When is last payment due?___________ Keep or surrender? _________________ Copy of installment note  please provide_________ Secured Creditor 2 (Describe items purchased)_____________________________________ Finance/loan company:_____________________________ Acct #:__________________________ Address:_________________________________________ Monthly payment: $______________ City:_________________ ST: ______ Zip:___________ Total loan payoff: $_______________ In whose name:___________________ Co-signers:_____________________________________ When did you take out loan:______________________ When is last payment due?___________ Keep or surrender? _________________ Copy of installment note  please provide_________ Secured Creditor 3 (Describe items purchased)_____________________________________ Finance/loan company:_____________________________ Acct #:__________________________ Address:_________________________________________ Monthly payment: $______________ City:_________________ ST: ______ Zip:___________ Total loan payoff: $_______________ When did you take out loan:______________________ When is last payment due?___________ Keep or surrender? _________________ Copy of installment note  please provide_________ Student Loans Student Loan Creditor 1 Student loan lender:_____________________________ Acct #:__________________________ Address:_________________________________________ Monthly payment: $______________ City:_________________ ST: ______ Zip:___________ Total loan payoff: $_______________ In whose name:___________________ Co-signers:_____________________________________ When did you take out loan:___________ When is last payment?:______________________ Is loan in default?_____ Is loan in deferment?:__________ When is deferment over?_________ Student Loan Creditor 2 Student loan lender:_____________________________ Acct #:__________________________ Address:_________________________________________ Monthly payment: $______________ City:_________________ ST: ______ Zip:___________ Total loan payoff: $_______________ In whose name:___________________ Co-signers:_____________________________________ When did you take out loan:___________ When is last payment?:______________________ Is loan in default?_____ Is loan in deferment?:__________ When is deferment over?_________ Health Club/Spa Membership Health Club Finance Company:______________________________________________ Address:_________________________________________ Monthly payment: $______________ City:_________________ ST: ______ Zip:___________ Total loan payoff: $_______________ In whose name:___________________ Co-signers:_____________________________________ Do you still use facility:___________ Did you sign a contract:_________________________ Do you want to continue to use this facility/club:_____________________________________ Credit Cards Credit Card Lender 1:____________________________ Acct #:__________________________ Correspondence Address:____________________________________ Monthly pymt: $______________ City:_________________ ST: ______ Zip:___________ Total loan payoff: $_______________ In whose name:___________________ Co-signers:_____________________________________ When did you first obtain this card?________________ When is last time you used this card?______________ Total charged in last 6 months?__________ Collection agency name, address, acct #:________________________________________________ ________________________________________________________________________________ Credit Card Lender 2:____________________________ Acct #:__________________________ Correspondence Address:____________________________________ Monthly pymt: $______________ City:_________________ ST: ______ Zip:___________ Total loan payoff: $_______________ In whose name:___________________ Co-signers:_____________________________________ When did you first obtain this card?________________ When is last time you used this card?______________ Total charged in last 6 months?__________ Collection agency name, address, acct #:________________________________________________ ________________________________________________________________________________ Credit Card Lender 3:____________________________ Acct #:__________________________ Correspondence Address:____________________________________ Monthly pymt: $______________ City:_________________ ST: ______ Zip:___________ Total loan payoff: $_______________ In whose name:___________________ Co-signers:_____________________________________ When did you first obtain this card?________________ When is last time you used this card?______________ Total charged in last 6 months?__________ Collection agency name, address, acct #:________________________________________________ Credit Card Lender 4:____________________________ Acct #:__________________________ Correspondence Address:____________________________________ Monthly pymt: $______________ City:_________________ ST: ______ Zip:___________ Total loan payoff: $_______________ In whose name:___________________ Co-signers:_____________________________________ When did you first obtain this card?________________ When is last time you used this card?______________ Total charged in last 6 months?__________ Collection agency name, address, acct #:________________________________________________ ________________________________________________________________________________ Credit Card Lender 5:____________________________ Acct #:__________________________ Correspondence Address:____________________________________ Monthly pymt: $______________ City:_________________ ST: ______ Zip:___________ Total loan payoff: $_______________ In whose name:___________________ Co-signers:_____________________________________ When did you first obtain this card?________________ When is last time you used this card?______________ Total charged in last 6 months?__________ Collection agency name, address, acct #:________________________________________________ ________________________________________________________________________________ Credit Card Lender 6:____________________________ Acct #:__________________________ Correspondence Address:____________________________________ Monthly pymt: $______________ City:_________________ ST: ______ Zip:___________ Total loan payoff: $_______________ In whose name:___________________ Co-signers:_____________________________________ When did you first obtain this card?________________ When is last time you used this card?______________ Total charged in last 6 months?__________ Collection agency name, address, acct #:________________________________________________ Credit Card Lender 7:____________________________ Acct #:__________________________ Correspondence Address:____________________________________ Monthly pymt: $______________ City:_________________ ST: ______ Zip:___________ Total loan payoff: $_______________ In whose name:___________________ Co-signers:_____________________________________ When did you first obtain this card?________________ When is last time you used this card?______________ Total charged in last 6 months?__________ Collection agency name, address, acct #:________________________________________________ ________________________________________________________________________________ Credit Card Lender 8:____________________________ Acct #:__________________________ Correspondence Address:____________________________________ Monthly pymt: $______________ City:_________________ ST: ______ Zip:___________ Total loan payoff: $_______________ In whose name:___________________ Co-signers:_____________________________________ When did you first obtain this card?________________ When is last time you used this card?______________ Total charged in last 6 months?__________ Collection agency name, address, acct #:________________________________________________ ________________________________________________________________________________ Credit Card Lender 9:____________________________ Acct #:__________________________ Correspondence Address:____________________________________ Monthly pymt: $______________ City:_________________ ST: ______ Zip:___________ Total loan payoff: $_______________ In whose name:___________________ Co-signers:_____________________________________ When did you first obtain this card?________________ When is last time you used this card?______________ Total charged in last 6 months?__________ Collection agency name, address, acct #:________________________________________________ ________________________________________________________________________________ Medical Bills Medical provider 1:__________________________________ Acct. #:____________________ Address:_________________________________________ Monthly payment:_____________ City:_____________________ ST: _________ Zip:__________ Total balance due:__________ In whose name:_____________________ Co-signers:___________________________________ Do you still use this health care provider?______________ When last used:__________________ Collection agency name, address, acct #_______________________________________________ _______________________________________________________________________________ Medical provider 2:__________________________________ Acct. #:____________________ Address:_________________________________________ Monthly payment:_____________ City:_____________________ ST: _________ Zip:__________ Total balance due:__________ In whose name:_____________________ Co-signers:___________________________________ Do you still use this health care provider?______________ When last used:__________________ Collection agency name, address, acct #_______________________________________________ _______________________________________________________________________________ Medical provider 3:__________________________________ Acct. #:____________________ Address:_________________________________________ Monthly payment:_____________ City:_____________________ ST: _________ Zip:__________ Total balance due:__________ In whose name:_____________________ Co-signers:___________________________________ Do you still use this health care provider?______________ When last used:__________________ Collection agency name, address, acct #_______________________________________________ Medical provider 4:__________________________________ Acct. #:____________________ Address:_________________________________________ Monthly payment:_____________ City:_____________________ ST: _________ Zip:__________ Total balance due:__________ In whose name:_____________________ Co-signers:___________________________________ Do you still use this health care provider?______________ When last used:__________________ Collection agency name, address, acct #_______________________________________________ _______________________________________________________________________________ Medical provider 5:__________________________________ Acct. #:____________________ Address:_________________________________________ Monthly payment:_____________ City:_____________________ ST: _________ Zip:__________ Total balance due:__________ In whose name:_____________________ Co-signers:___________________________________ Do you still use this health care provider?______________ When last used:__________________ Collection agency name, address, acct #_______________________________________________ _______________________________________________________________________________ Medical provider 6:__________________________________ Acct. #:____________________ Address:_________________________________________ Monthly payment:_____________ City:_____________________ ST: _________ Zip:__________ Total balance due:__________ In whose name:_____________________ Co-signers:___________________________________ Do you still use this health care provider?______________ When last used:__________________ Collection agency name, address, acct #_______________________________________________ _______________________________________________________________________________ Other Creditors/Extra space Pension or 401(k) Loans Type of investment ____________________________ Acct #:__________________________ Address:_________________________________________ Monthly payment: $______________ City:_________________ ST: ______ Zip:___________ Total loan payoff: $_______________ In whose name:___________________ Co-signers:_____________________________________ When did you take loan out?_________________ How long will loan last?_________________ ________________________________________________________________________________ Personal Loan:____________________________ Who is this person:____________________ Address:_________________________________________ Monthly payment: $______________ City:_________________ ST: ______ Zip:___________ Total loan payoff: $_______________ In whose name:___________________ Co-signers:_____________________________________ What type of debt is this?_________________________________ What did you buy:___________ Collection agency name, address, acct #:________________________________________________ ________________________________________________________________________________ Personal Loan :____________________________ Who is this person:__________________ Address:_________________________________________ Monthly payment: $______________ City:_________________ ST: ______ Zip:___________ Total loan payoff: $_______________ In whose name:___________________ Co-signers:_____________________________________ What type of debt is this?_________________________________ What did you buy:___________ Collection agency name, address, acct #:________________________________________________ ________________________________________________________________________________ Creditor/Lender :____________________________ Acct #:__________________________ Address:_________________________________________ Monthly payment: $______________ City:_________________ ST: ______ Zip:___________ Total loan payoff: $_______________ In whose name:___________________ Co-signers:_____________________________________ What type of debt is this?_________________________________ What did you buy:___________ Collection agency name, address, acct #:________________________________________________ ________________________________________________________________________________ Creditor/Lender :____________________________ Acct #:__________________________ Address:_________________________________________ Monthly payment: $______________ City:_________________ ST: ______ Zip:___________ Total loan payoff: $_______________ In whose name:___________________ Co-signers:_____________________________________ What type of debt is this?_________________________________ What did you buy:___________ Collection agency name, address, acct #:________________________________________________ ________________________________________________________________________________ Creditor/Lender :____________________________ Acct #:__________________________ Address:_________________________________________ Monthly payment: $______________ City:_________________ ST: ______ Zip:___________ Total loan payoff: $_______________ In whose name:___________________ Co-signers:_____________________________________ What type of debt is this?_________________________________ What did you buy:___________ Collection agency name, address, acct #:________________________________________________ ________________________________________________________________________________ For Attorney s Use Only -Debt Analysis Worksheet ________ 1._______________________________________________ ___________ ___________ ________ 2._______________________________________________ ___________ ___________ ________ 3._______________________________________________ ___________ ___________ ________ 4._______________________________________________ ___________ ___________ ________ 5._______________________________________________ ___________ ___________ ________ 6._______________________________________________ ___________ ___________ ________ 7._______________________________________________ ___________ ___________ ________ 8._______________________________________________ ___________ ___________ ________ 9._______________________________________________ ___________ ___________ ________ 10_______________________________________________ ___________ ___________ ________ 11._______________________________________________ ___________ ___________ ________ 12._______________________________________________ ___________ ___________ ________ 13._______________________________________________ ___________ ___________ ________ 14._______________________________________________ ___________ ___________ ________ 15._______________________________________________ ___________ ___________ ________ 16._______________________________________________ ___________ ___________ ________ 17._______________________________________________ ___________ ___________ ________ 18._______________________________________________ ___________ ___________ Total Arrearage:______________________ Total Priority:___________________________ Total Secured:_______________________ Total unsecured (100%)___________________ Total general unsecured:_______________ Total non-exempt equity:__________________ Estimated plan payment:_______________ % Plan:___________________________ Emergency Action AlertForeclosure?Repossession?Wage Garnishment? Does payment include taxes & insurance? 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