Have you been in business for yourself at any
time within the past six years?
Yes
No
Are you in business for yourself at this time?
Yes
No
Have either you or your spouse ever filed any
case in bankruptcy court?
Yes
No
During the past three months, have you lived
ANYWHERE except in Los Angeles County?
Yes
No
Are there any lawsuits against you? Have you
been served with lawsuit papers?
Yes
No
Do you have any earnings, wages or a car being
held under attachment or garnishment?
Yes
No
Do you owe any taxes?
Yes
No
Do you owe any child support?
Yes
No
What is your martial status?
Single
Married
Separated
Widowed
Divorced
Interlocutory
Final Decree
How many minor children do you support?
What kind of work do you usually do?
Who is your present employer?
How long have you worked for your present employer?
Do you get paid weekly, monthly, or how?
When is your next pay day?
Each pay day you GROSS about how much?
Each pay day you BRING HOME about how much?
In addition to your pay checks, what other income do you
have?
How much gross income does your spouse earn each month?
Is there anyone you think might die in the next
six months and leave something to you?
Yes
No
Are you presently entitled to an inheritance
and have not received it, or expect that you will become entitled
to an inheritance in the next 12 months?
Yes
No
Have you, within the last 12 months, paid $1,000.00
or more to a relative, friend or any business associate?
Yes
No
Did you, within the past four years, sell anything
of value to someone else or transfer anything of value (such
as real estate, etc.) to someone else or put something of
value in the name of some other person?
Yes
No
Are there any outstanding debts where you signed
your name and co-signed for someone else?
Yes
No
Do you have debts that were co-signed for you
by someone else, or made jointly with someone else?
Yes
No
How much money in the form of cash, checks (such
as paychecks you haven’t cashed), money orders, cashier’s
checks or travelers checks do you have?
Do you or your spouse have a checking account,
savings account, credit union or other accounts?
Yes
No
Have you bought any “luxury goods or services”
on credit within the past 60 days?
Yes
No
Have you received any cash advances on credit
within the past 60 days? (This does not mean your regular
paycheck from your job.)
Yes
No
Approximately how much money do you owe on credit
cards and other similar debts?
Do you have a retirement plan at work?
Yes
No
If so, how much is it worth?
Do you have an IRA or other personal retirement
monies?
Yes
No
If so, please list below:
Is there any property of any kind, including
bank accounts, money in a savings and loan association, money
in a credit union, stocks or bonds, automobiles, real estate,
or anything else of value, in your name or the name of your
spouse or your children that you have not mentioned before?
(Not including furniture and appliances)
Yes
No
If yes, please list below:
Do you have a claim against anyone for personal
injury, property damage, breach of contract or for any other
reason?
Yes
No
If yes, please list details:
Do you have any real estate such as a house
or condo?
Yes
No
If so, what would it sell for?
Do you own any interest in any other real estate?
Yes
No
If yes, please list details:
About what would it sell for?
If you have some real estate, has anyone started
a foreclosure against it?
Yes
No
If any of your real estate is in foreclosure,
has a date of sale been set by the mortgage holder?
Yes
No
If so, when is the sale date?
