Questionnaire How Can Our Hawaii Bankruptcy Attorneys Help You? Would you like to know more about how the Law Office of Blake Goodman can help you with your financial problems? Please take a moment to fill out the information on this page and click "submit" at the bottom. A Hawaii bankruptcy lawyer will reply as soon as possible. If there is not enough space to complete your responses, then please put carry over information in the "General Comments" section at the end of this questionnaire.Date MM DD YYYY Have you made an appointment with our office yet?*NOYESFor what day?NameFirst NameMILast NameSpouse's NameFirst NameMILast NameContact InfoMailing Address (Apt. #)City, State, ZipPhone Number*Work Phone (ext.)Email* EmployerEmployer, PositionSpouse's Employer, PositionQuestionnaireHow Did You Hear About Us?Select OneRadioRecommendationInternet SearchYelpOtherHow?How long have you lived at your present address?Marital StatusMarriedSingleDivorcedSeparatedFor how long?Do you have any children under the roof with you or are otherwise dependents?NOYESHow Many?What are their ages?Do You own any real estate?NOYESWhat is its value (best guess), please list allDo you own any burial plots/plans or timeshares?NOYESWhat is its value (best guess), please list allDo you have any vehicles?NOYESYear, Make, Model, Value (best guess), please list allDo you own or operate a business?NOYESWhat type?Do you have any of the following property? Savings Account Stocks, Bonds, Investments Retirement Account Have you ever filed Bankruptcy before?NOYESWhen, what type, and where?Are you suing anybody or is anybody suing you?NOYESExplainCould you sue anybody?NOYESLate PaymentsDo you or your spouse pay child support?NOYESAre you behind on payments?N/AYESNOBy how much?Are you paying on a house or vehicle?NOYESAre you behind on these payments?N/AYESNOPaying on/# of Months behind? Please list allDo you have any student loans?NOYESTotal amounts?Do you owe any Federal, State, Sales, or Property taxes?NOYESFor what years?Are any of your debts co-signed with anyone other than your spouse?NOYESWhich ones and by whom?Are you paying any debts back to family members?NOYESTo whom & how much paid in the last 12 months?IncomeWhat is your approximate take home income per month (not per pay period) after deductions for taxes, social security, and insurance? (Please include spouse's income whether filing a case with you or not)JobYouYour Spouse 2nd JobYouYour Spouse BusinessYouYour Spouse Food StampsYouYour Spouse Child SupportYouYour Spouse RetirementYouYour Spouse Other SourcesYouYour Spouse Are there any special deductions out of your pay?YouMonthly Retirement Contribution?NOYESHow Much?Monthly Repayments On Loans To Employer?NOYESHow Much?Monthly Allotments To Creditors?NOYESHow Much?Your SpouseMonthly Retirement Contribution?NOYESHow Much?Monthly Repayments On Loans To Employer?NOYESHow Much?Monthly Allotments To Creditors?NOYESHow Much?ExpensesWhat are your approximate expenses per month for the following items?Mortgage/Rent2nd Mortgage3rd MortgageMaintenance FeeMedicalElectricityLaundryWaterHair CutsGasCableTelephoneGasoline: (All Vehicles)Furniture/Appliance PaymentCar MaintenanceClothingCar PaymentsCar InsuranceChild SupportFoodChildcareANY OTHER EXPENSES(Ex: Diapers, Dog Food, Cigarettes)Mortgages and Other House Related DebtsName of CreditorBalance (Best Guess)Value of Real Estate Car DebtsName of CreditorBalance (Best Guess)Type & Year of Car Credit CardsName of CreditorBalance (Best Guess) Signature Loans with CollateralName of CreditorBalance (Best Guess) Signature Loans without CollateralName of CreditorBalance (Best Guess) Medical BillName of CreditorBalance (Best Guess) Student LoansName of CreditorBalance (Best Guess) Loans to Family and FriendsName of CreditorBalance (Best Guess) OthersName of CreditorBalance (Best Guess) Back Tax DebtName of CreditorType of TaxYearBalance General CommentsPlease place overflow information here.I agree that all information provided on this document is ready to submit*Select OneI AgreeI DisagreeNameThis field is for validation purposes and should be left unchanged.