The Law Offices of John T. Orcutt

Online Consultation Form

After filling out the following forms, we will have the basic information needed to provide you with an effective analysis of your situation and determine the type of bankruptcy best suited to your circumstances and whether or not bankruptcy is even the best option available for you during your FREE half hour office consultation.

Once we receive your online consultation information, a staff member will contact you to schedule a FREE half hour consultation for you with Kathy A. Cruz, Arkansas' Only Board Certified Consumer Bankruptcy Attorney (certified by the American Board of Certification).

It is important to remember to answer all questions completely and honestly in order to give Kathy A. Cruz the opportunity to provide you with the best guidance according to your individual needs. The more complete the information you provide to us, the more value we will be able to provide to you.

Clients with questions may contact us at: 501-624-3600 or Toll-free 888-647-3328.

The Cruz Law Firm, P.L.C., is dedicated to personal service and a swift, effective resolution to their client's financial problems. They have handled many Chapter 7 & Chapter 13 bankruptcy cases and have the resources, skills and experience to protect your assets and help you regain control of your financial situation.

All information on this form is private and strictly confidential. The Cruz Law Firm, P.L.C., will use this information only to assess your financial situation and will NOT sell or provide this information to any organizations.

Your Information

* = Required Information

Your Name*

Social Security #* Driver's License # * Email *

Spouse Name

Social Security #* Driver's License # * Email *

Other Names used in the Last six (6) Years
(Include Nick-names, previous married names, or other names on any debts)

County*

Home Address* ,

Mailing Address ,
(if different)

Home Phone () - Emergency Phone () -

Your Employer How Long

Address ,

Phone () -

When Paid? Weekly Bi-Weekly Monthly Semi-Monthly
(check one)

Spouse Employer How Long

Address ,

Phone () -

When Paid? Weekly Bi-Weekly Monthly Semi-Monthly
(check one)

What is your monthly household net income (after taxes, take home income)?
(Include your spouse's income even if you intend to file individually)
You $ Spouse $

Marital Status Divorced Widowed Never Married Married Separated
(check one)

Have you lived at your current address for at least six (6) months? Yes No

Is this business related? (Are you filing as or for a business?) Yes No

Your Information

(check all that apply, and list approximate amounts)

Credit Cards $ Bounced Checks $

Medical Bills $ Payday Loans $

Back Taxes $ Student Loans $

Repossession       $                                                            Signature Loans        $
                                                                                                                        (loans with no collateral)
Back Child            $                                                            Other Please describe
     Support

How much debt do you have not counting vehicles or mortgages? Please describe

How many creditors do you believe you have? Please describe

If you have credit card debt, when was the last time you charged? If it was within the last 90 days, please list amounts and types of purchases

Your Information

Do you own, or are you purchasing any vehicles? Yes No

If you answered "Yes" above complete the following information:

Vehicle 1 , ,

Fair Market Value $ Balance Owed $

Monthly Payment $

Are you behind on this vehicle? Choose one

If yes, how much are you behind?

What are your intentions with this vehicle? Choose one

Vehicle 2 , ,

Fair Market Value $ Balance Owed $

Monthly Payment $

Are you behind on this vehicle? Choose one

If yes, how much are you behind?

What are your intentions with this vehicle? Choose one

Vehicle 3 , ,

Fair Market Value $ Balance Owed $

Monthly Payment $

Are you behind on this vehicle? Choose one

If yes, how much are you behind?

What are your intentions with this vehicle? Choose one

Your Information

Do you own any real estate? Yes No

If you answered "Yes" above, complete the following information: (otherwise, just click "Submit")

How many mortgages do you have on your property?

How much is owed on each mortgage?

First Mortgage: $, Second Mortgage: $, Third Mortgage: $

What do you think you could sell the home for if you wanted to? $

Do you have any other real estate other than that described above?

If so, please describe here.

Your Information

Describe any other assets you won that have significant value.

Description
Approximate Value $

Your Information

What did you show for taxable income on your most recent tax return (AGI)?

Do you owe the IRS or state for back taxes?

YES NO

Are there any years for which you have not filed state or federal income tax returns?

YES NO

If yes, what years?

Did you get a tax refund last year?

YES NO

If yes, how much? $

Your Information

Have you ever filed bankruptcy before?
YES NO

If yes, what year?

what chapter

In the last two years have you given or paid more than $500 to any friend or relative?
YES NO

Does anyone owe you any money?
YES NO

Amount:
$

Have creditors been calling you at home or work?
(Home) YES NO
(Work) YES NO

Have you been served with a summons in the last year?
YES NO

Have you been involved in a law suit in the last year?
YES NO

If you answered yes above, please give brief description of the law suit:

Are your wages being garnished?
YES NO

Are you behind on your home and/or car payment?
YES NO

Your Information

Please List Amounts for the Following:

Monthly Amount	Type of Expense
	Home: Rent / Home mortgage / Mobile home payment (include lot rent, if any)
	Utilities: Electricity
	Gas or Oil
	Water and sewer
	Telephone
	Cablevision / Satellite (circle one)
	Garbage pickup
	Other (describe):
	Home Maintenance (routine repairs and upkeep)
	Food, household cleaning supplies, paper products for the house, health and grooming necessities)
	Clothing
	Laundry and Dry Cleaning (soap powder, bleach, dryer sheets, fabric softener, Laundromat use)
	Medical and Dental Expenses: Prescriptions, OTC drugs/vitamins, Doctor co-pays
	Transportation and Vehicle Expenses (Gas (how much each week)/ Repairs (number of oil changes in one (1) year (for all vehicles)/cost of each/cost for set of tires) / Maintenance / Cab or Bus Fare) Inspections
	Recreation, Clubs, Entertainment, Newspapers, Magazines, Etc.
	Religious / Tithing / Charitable Contributions (list Church name/title):
	Insurance:
	Property Insurance on home
	Is this expense included in your house payment? Yes No
	Renter's Insurance
	Car / Truck Insurance
	Life and Disability
	Health and Dental
	Other (describe):
	Taxes: (Not including the taxes deducted from your wages)
	Real Estate taxes
	Is this expense included in your house payment? Yes No
	Personal Property taxes (On vehicles and/or business equipment)
	Estimated Income taxes (If you are self-employed)
	Overdue Income taxes

	Overdue Withholding/Sales taxes (If you are self-employed or from a business)
	Installment payments (purchase or lease):
	Motor Vehicle
	Motor Vehicle
	Motor Vehicle
	Mobile Home (Other than your home)
	Furniture
	Furniture
	Jewelry
	Boat 4-Wheeler Camper Other Recreational Vehicles
	Other (describe):
	Other (describe):
	Alimony and Child Support paid to others
	Payments for support of additional dependents not living at your home
	Business Expenses (Regular expenses for operation of a current business, profession or farm)
	If so, please attach a list of the monthly business expenses and the amounts.
	Child Care
	Co-signed debts that must be paid
	Student loans
	Prospective Vehicle Purchase / Additional insurance
	Regular Monthly Expenses of Non-filing spouse or Live-in boyfriend/girlfriend:
	Describe:
	Describe:
	Describe:
	Describe:
	Describe:
	Emergencies
	Miscellaneous
	Personal Grooming
	Other expenses (describe):
	Other expenses (describe):
	TOTAL