Client Questionnaire For Non-Business Debtor

Client Questionnaire For Non-Business Debtor

Section 1 Basic Information Part A. Name and Address

Name: ______________________________________________________________________

Last                                    First                                                          Middle

Telephone Number Home:______________________________ Work:____________________

Have you used any other names in the past eight years? □ No □ Yes If yes, list other names:

Social Security Number:______________ -_________ -__________________

Address: _____________________________________________________________________

City: _______________________________  State:_______________ Zip:_________________

County: ________________________

Have you lived at this address for at least 180 days? □ No □ Yes

Have you lived at this address for at least 730 days (2 years)? □ No □ Yes

If you answered no to either of the questions above, please list your previous address:

Address:_____________________________________________________________________

City: _____________________________  State:_____________ Zip:_____________________

County:__________________

If you have a different mailing address, please list: Mailing Address:

City: _____________________________  State:_____________ Zip:_____________________

Part B. Name and Address of Spouse

If you are filing jointly with your spouse, fill in the following information about your spouse:

Name: ______________________________________________________________________

Last                                    First                                                          Middle

Has your spouse used any other names in the past eight years? □ No □ Yes If yes, list other names:

Social Security Number:______________ -_________ -__________________

Address: (if different from your address):

______________________________________________________

City: _____________________________  State:_____________ Zip:_____________________

County:___________

If your spouse has a different mailing address, please list:

Mailing Address:____________________________________________________________________

City: _____________________________  State:_____________ Zip:_____________________