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Confidential Case Assessment

Bold labels and indicate required information.

Have you filed bankruptcy before?


RENTING HOME

Are you leasing your residence?


Do you intend to assume/keep the lease?


PURCHASING HOME

PURCHASE OF OTHER REAL ESTATE

VEHICLES-CARS / BOATS / MOTORCYCLES / TRAILERS / RECREATIONAL VEHICLES

VEHICLE 1

VEHICLE 2


VEHICLE 3

VEHICLE 4

PERSONAL PROPERTY

DO YOU OWN OR HAVE ANY INTEREST IN ANY OF THE FOLLOWING:


OTHER PROPERTY ISSUES

Have you had a workrelated injury or other medical condition within the last 2 years?


If yes, have you filed a claim?


Have you had any other injuries in the last 5 years?


If yes, have you filed a claim?


Have you transferred any property or money to another individual in the last 4 years?


Have you filed all tax returns that you are required to file?


Were you/are you entitled to a tax refund?


OTHER DEBTS(ESTIMATE IF UNKNOWN)
CREDIT CARD ISSUES

Have you taken any cash advances in the last 70 days totaling $750 or more?


Have you made any luxury purchases in the last 90 days totaling $500 or more?


OTHER ISSUES

Do you owe money to the bank with which you also have a bank account?


Have you signed any nonresidential leases or rental agreements (e.g. RentACenter, car, etc.)?


HOUSEHOLD INFORMATION

EMPLOYMENT-PRIMARY

EMPLOYMENT-2ND JOB


EMPLOYMENT-SPOUSE

EMPLOYMENT-SPOUSE 2ND JOB

OTHER INCOME
MONTHLY EXPENSESDO NOT INCLUDE PAST DUE AMOUNTS







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The Law Offices of Steven K. Brown, with offices in St. Louis and Brentwood, Missouri, serves clients in Ballwin, Chesterfield, Richmond Heights, Florissant, Ferguson, Clayton, Kirkwood, Oakville, Wildwood, Manchester, Northwoods, Hazelwood, Olivette, University City, St. Louis County, Jefferson County, St. Charles County, Franklin County, Lincoln County and Warren County.

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