Free Case Evaluation

Please fill in as many of the following fields as you can.

Full Name

Address

Phone

Email Address

Best time to contact you?

What type of bills do you have?
(Check all that apply)

Credit Cards
Medical Bills
Judgements
Student Loans
Tax Debts
Government Fines
Personal Loans

Number of bills

Amount Owed:

Under $5,000
$5,000 - $10,000
$10,000 - $15,000
$15,000 - $20,000
$20,000 - $30,000
$30,000 - $40,000
$40,000 - $50,000
Over $50,000

Approximate value of home:

Approximate balance on mortgage:

Monthly mortgage payment:

Are you up to date on your mortage payments?

Yes
No

Are there any other mortgages on this property?

Yes
No

Vehicle 1
Year/Make/Model:

Approximate Value:

Approximate Balance:

Monthly Payment:

Are your payments up to date?

Yes
No

Vehicle 2
Year/Make/Model:

Approximate Value:

Approximate Balance:

Monthly Payment:

Are your payments up to date?

Yes
No

Enter any other property of significant value. (For example, if you own a boat, list it here.)

You
Are you employed?

Yes
No

How often do you get paid?

every week
every 2 weeks
twice a month
monthly

Net Pay:
(after taxes, medical adn other deductions)

What other types of income do you have?
(Check all that apply)

Disability
Social Security
Pension
Rental Property
Part Time Job
Child Support
Unemployment
Workers Compensation

Spouse (optional)
How often do you get paid?

every week
every 2 weeks
twice a month
monthly

Net Pay:
(after taxes, medical and other deductions)

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Address: 220 Old Country Road, 1st Floor Mineola, NY 11501 Phone: (516) 619-8258