Gustafson Law Office, P.L.L.C. - Free Debt Evaluation

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*Daytime Phone Number:
Cell Phone Number:
Evening Phone Number:
Email:
Name(s) (optional):
Address (optional):

Total Credit Card Debt ($):
Total Medical Bill Debt ($):
Other Unsecured Debts, if any ($):

Do You own a House?			Yes No
Total Payoff Balance on Mortgage(s) ($):
Market Value of house ($):
Current on Payments?			Yes No

Do You own any Vehicle(s)?			Yes No
Vehicle #1:	Year:	Make:	Model:
Total Payoff Balance, if any ($):

Vehicle #2:	Year:	Make:	Model:
Total Payoff Balance, if any ($):

Marital Status:			Married
			Single
			Divorced

Total Combined Monthly Income after Taxes (Net Income) ($):
If applicable, Husband’s Net Monthly Income ($):
If applicable, Wife's Net Monthly Income ($):
Have any debt collection lawsuits been filed against you?			Yes No

Other Information: