Debt Problem Questionnaire

First Name: *   Last Name: *
 
     
Home Address:    
Number and Street:    
   
     
City: *   State: *
 
     
Day Phone *   Cell Phone
 
     
Do you own a home? *   How much is your home worth? *
Yes No  
     
How much do you owe for all mortgages, home equity loans, etc?*
   
     
Do you own a car?*   How many? *
 
     
Do you have unsecured debt (credit card bills, medical bills, utility bills, etc)?*
   
     
If so, what is the total of all of your unsecured debt? *
   
     
DISCLAIMER and STATEMENT OF NON-CONFIDENTIALITY
Information sent to Pachtman Law Office using this form is protected using standard Internet encryption technology. We will treat this information confidentially; however, submitting this information does not create an attorney-client relationship of any kind. The information on this site is not meant as legal advice nor does it constitute an offer to represent you.
     
     
   
     

 

 

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