100%
Questions marked with an * are required Exit Survey
 
Debtor
* First Name : 
* Last Name : 
* Email  : 
   DOB : 
* Address : 
    * State     * Zip
* Cell Phone : 
SSN : 
 
 
Spouse (Even if not Filing)
First Name : 
Last Name : 
Email : 
DOB : 
Address : 
    State     Zip
Cell Phone : 
SSN : 
 
 
 
* Are you facing a foreclosure (even if there is no date yet)?
 
Yes
 
No
 
 
 
* Are you on the deed to any house, land or timeshare (even if you are not on the mortgage)?
 
Yes
 
No
 
 
 
* Have you lived in Maryland consecutively for more than the last 2 years?
 
Yes
 
No
 
 
 
* Have you had any previous bankruptcy filings in the last 8 years ?
 
Yes
 
No
 
 
 
* Have you had any past foreclosures or repossessions of a house or car in the last 2 years?
 
Yes
 
No
 
 
 
* Have you owned or operated a business or side business in the last 2 years?
 
Yes
 
No
 
 
 
* Do you own or rent at your current address?
 
Own
 
Rent
 
 
 
* Do you have a Home Owner's Association Fee?
 
Yes
 
No
 
 
 
* Marital Status
 
Single
 
Married
 
Separated
 
 
 
* Do you owe State or Federal Taxes?
 
Yes
 
No
 
 
 
* Have you given away or otherwise transferred any money or any kind of property worth more than $1000 in the last 3 yrs (including family or friends)?
 
Yes
 
No
 
 
 
* Have you sold any kind of property worth more than $1000 in the last 3 yrs (including to family or friends)?
 
Yes
 
No
 
 
 
* Have you made any payment to any creditor or any person over $1000 for any purpose besides mortgage or car in the last 6 months?
 
Yes
 
No
 
 
 
* Do you have any lawsuits you could file or are thinking about filing?
 
Yes
 
No
 
 
 
* Are you the beneficiary, grantor or trustee of any trust?
 
Yes
 
No
 
 
 
* Did you receive any money or checks of $1000 or more aside from work paystubs in the last year?
 
Yes
 
No
 
 
 
* Are you behind on child support or alimony payments to anyone?
 
Yes
 
No
 
 
Dependents in Household
Name Age Gender Do they work?
Child 1
Child 2
Child 3
Child 4
Child 5
 
 
Real Property House/ Condo/ Land if you are on the deed, even if you are not on the mortgage
Street Address City State Zip Total Principal Balance 1st Mortgage Creditor 1st Mortgage Payment 2nd Mortgage Creditor 2nd Mortgage Payment
House 1
House 2
House 3
 
 
Motor Vehicles
Year Brand Model Mileage Creditor Monthly Payment
Car 1
Car 2
Car 3
Car 4
 
 
Checking/ Saving / Investments Stocks Bonds Funds / Paypal / Any Other Financial Accounts
Name of Bank Average Daily Balance
Account 1
Account 2
Account 3
Account 4
Account 5
Account 6
Account 7
 
 
Employer
Company Name Payroll Street Address & Zip Annual Salary Job Title How Long Worked There?
Debtor
Spouse
 
 
Other Monthly Income
Monthly Amount of Income
Rental Income
Partner Contribution
Family Contribution
Unemployment
Social Security
Pension
Child Support or Alimony
Veterans Benefits
Other Benefits
2nd Job
Business Income
Other Income
 
 
Monthly Expenses
Monthly Cost Approximate Average
House Mortgage/Rent Payment
2nd Mortgage / Equity Line Payment
House HOA
Home Taxes and Insurance if not included in mortgage payment
Gas/Electric Combined
Water/Sewer/Garbage
Cable Internet Landline
Cell Phone
Home Repairs
Food
Monthly Cost Approximate Average
Clothing
Medical Including Copays Dental
Entertainment
Charitable Contributions
Personal Grooming
Pet Care
Child Support or Alimony Payments
Car Insurance
Life Insurance
Renters Insurance
Monthly Cost Approximate Average
Home Alarm
Car Gasoline
Car Repairs
Car Payment 1
Car Payment 2
Parking
Metro/ Uber
Daycare Aftercare
Student Loans
Kids Activities
Assistance to Family
Other
Tuition
 
 
Debt Information
Approx # Items Approx Total Combined Balances Approx Total Charges Last 6 Months Payment Amount Last 3 Months
Mortgage Arrears
HOA Arrears
Rent Arrears
Credit Cards
Medical Bills
Personal Loans
Repossessions
Student Loans
Child Support Arrears
MD MVA or tickets
Approx # Items Approx Total Combined Balances Approx Total Charges Last 6 Months Payment Amount Last 3 Months
Federal Taxes
State Taxes
Property Taxes
Judgments
Liens
Unemployment Overpayment
Broken Apartment Leases
Utilities
Payday Loans
Title Loans
Small Business Debt
Furniture Loans
Other
 
 
 
* Make a detailed list of furniture, all electronics, collectibles, antiques you own: (Do not put n/a or none)
   
 
 
 
* Make a detailed list of clothing and accessories you own: (Do not put n/a or none)
   
 
 
 
* Make a detailed list of jewelry, watches, furs, accessories, other valuables (Do not put n/a or none)
   
 
Share This Survey:          Surveys Powered by  QuestionPro Survey Software