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Let us help you! Complete the form below regarding your financial status and we will contact you after reviewing it. All information you provide is strictly confidential and will be deleted within 30 days.*

 Personal Info

First Name:

  

(required)

Last Name:

  

(required)

Email:

  

(required)

Address:

  

Apt/Floor:

  

City:

  

  State:   Zip:

Telephone:

  

(required)

Please specify day/time for a return call:      (required)
     

 Bills

What type of bills do you have?  Please check all that apply:

Credit Cards

Tax Debts

Medical Bills

Government Fines

     (parking tickets, moving
     violations, suspensions)

Judgments

Student Loans

Personal Loans

Total Number of Bills: 

Total Amount:  

 

Under $5,000

$10,000-$15,000

$15,000-$20,000

$20,000-$30,000

$40,000-$50,000

Over $50,000

Additional Info:

     

 Property

Home:

Approximate value of home: $

Balance on mortgage: $

Monthly mortgage payment: $

Are you up to date on your mortgage payments?  Yes  No   

Are there any other mortgages on this property?  Yes  Yes   

     

Vehicles:

Vehicle 1:

Year:  Make:  

Model:  

Value: $ 

Balance: $ 

Monthly payment: $ 

Are your payments  
up-to-date?  

Yes No   

 

Vehicle 2 (optional):

Year:  Make:  

Model:  

Value: $ 

Balance: $ 

Monthly payment: $ 

Are your payments  
up-to-date?  

Yes No   

     

Other:

Please list any other significant property:
     

 Income

You:

How often do you get paid?

Every week

Every 2 weeks

Twice a month

Monthly

Net pay: $

(after taxes, medical & other deductions)
 

Spouse:

How often do you get paid?

Every week

Every 2 weeks

Twice a month

Monthly

Net pay: $

(after taxes, medical & other deductions)
     

Other Income:

What other types of income do you have? Please check all that apply:

Disability

Part-time job

Social Security

Child Support

Pension

Unemployment

Rental Property

Worker's Compensation

*If you decide to work with Eric N. Klein & Associates, the information submitted may be retained for a longer period of time.

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