Short Intake Form,
For People Having Problems
Just With Unsecured (Non-Mortgage) Debt

Brought to you as a service of
debtworkout.com
Assisting Distressed Debtors, and
Rescuing Homes From Foreclosure Nationwide
150 North Street Suite 40, Pittsfield, MA 01201

     If you have a distressed automobile loan or distressed real estate, please use the Full intake form.
     Please complete each section on this form. In an area which requires a dollar amount, please enter "4000" instead of $4,000.00, "100000" instead of "$100,000.00" (no dollar sign, comma or period). Also, please note that placing any other characters in a dollar amount space, such as "about 1500 per month," will make your work unusable on our end.
     Later in this form, you'll be asked for the wholesale value(s) of your automobile(s). Since many browsers do not support jumping from a form and then returning to it without losing your work, please go to AutoPrices.Com now to get the values for your cars, write down the wholesale or loan value and then return here to work on the form. You will also be asked about the status of your credit. If you have no idea and would like to see your report on-line now for $8 find a link on themortgage tools page, otherwise make your best guess.

Please check which response you´re looking for from us, and remember that a fee based phone consultation must be pre-paid. If no option is selected, this form will not be processed:
We would appreciate knowing how you heard about us. Please take a moment to send us this information here:
We found your site in this way:
We didn't find your site like that, we found it like this:
My first name
My last name
My e-mail address (this will permit us
to speed confirmation of receipt and processing)
Co-Borrower's ("Co's") first name
Co's last name
My home phone
My significant other status is:
My street address is
My city, state and zip are:
At this residence, I
I am
If employed by another, that name is
My employer's address
I've worked here this many years
I've worked in this field this many years
My title or position is
My business phone, with area code, is
Co's street address is
Co's city, state and zip are:
Co is
If employed by another, that name is
Co's employer's address
Co's worked here this many years
Co's worked in this field this many years
Co's title or position is
Co's business phone, with area code, is
These questions are for employment information and other income information
My base monthly income
My monthly overtime
My monthly bonuses
My monthly commissions
My monthly interest/dividends
My total other (including things like social security, disability, alimony, child support) monthly income
Co's base monthly income
Co's monthly overtime
Co's monthly bonuses
Co's monthly commissions
Co's monthly interest/dividends
Co's total other (including things like social security, disability, alimony, child support) monthly income
What is your present rent or mortgage payment (enter "0" if not applicable)?
ASSETS and LIABILITIES .
If you have a real estate loan that is in trouble, please use the longer intake form.

This area may be completed jointly by both married and unmarried Co-Borrowers if their assets and liabilities are sufficiently joined so that the information can be meaningfully and fairly presented on a combined basis.
In this section, please list any bank or credit union where you have money deposited, the address, the account number, and the account balance.
Bank Name Address Account Number Account Balance
What is the value of your home, per your most recent tax bill (or a recent real estate appraisal or realtors price opinion if have received one)?
What is the total value of your automobile(s)? Check Car Prices.com® to get this information, and make sure to use the wholesale value.
List the names, number of shares and type of all stocks and bonds
List the total value of all stocks and bonds
If you have a vested interest in a retirement fund, 401K, IRA, what is the dollar amount?
If you own a business, what is the net value?
Describe all other assets (not including real estate)?
Total value of all other assets?

If it were necessary for you to come up with a lump sum cash payment today, in order to reach a settlement with your creditors, how much cash could you come up with?
Same question, but how much cash could you come up with 30 days from now?
Same question, but how much cash could you come up with 180 days from now?
Same question, but how much cash could you come up with 1 year from now?

How much do you spend each month, just to pay on all of the debts you are paying on?
How much could spend each month to cover debts?
Have you ever filed for bankruptcy protection?
If so, what chapter did you file under?
How is your credit right now?

   This section is for your debts. There are individual sections for non-distressed mortgage and car loans, and for up to ten unsecured creditors.
   If you are behind in either your car loans or your mortgage, please use the longer intake form.
   If you have more than ten unsecured creditors, go on to the continuation sheet, and list the additional creditors, together with the other information for them (type of debt, who owes, how much is due, last day paid, stage of collection) on that sheet.

What is the current balance (payoff amount) on your mortgage?
What is the current balance on your car loan(s)?

1st Creditor's name and address
Who owes on this account?
What kind of debt is this?
What is the total amount owed?
What was the last date you paid
anything on this debt?
If there is collection activity,
what stage is it at?

2nd Creditor's name and address
Who owes on this account?
What kind of debt is this?
What is the total amount owed?
What was the last date you paid
anything on this debt?
If there is collection activity,
what stage is it at?

3rd Creditor's name and address
Who owes on this account?
What kind of debt is this?
What is the total amount owed?
What was the last date you paid
anything on this debt?
If there is collection activity,
what stage is it at?

4th Creditor's name and address
Who owes on this account?
What kind of debt is this?
What is the total amount owed?
What was the last date you paid
anything on this debt?
If there is collection activity,
what stage is it at?

5th Creditor's name and address
Who owes on this account?
What kind of debt is this?
What is the total amount owed?
What was the last date you paid
anything on this debt?
If there is collection activity,
what stage is it at?

6th Creditor's name and address
Who owes on this account?
What kind of debt is this?
What is the total amount owed?
What was the last date you paid
anything on this debt?
If there is collection activity,
what stage is it at?

7th Creditor's name and address
Who owes on this account?
What kind of debt is this?
What is the total amount owed?
What was the last date you paid
anything on this debt?
If there is collection activity,
what stage is it at?

8th Creditor's name and address
Who owes on this account?
What kind of debt is this?
What is the total amount owed?
What was the last date you paid
anything on this debt?
If there is collection activity,
what stage is it at?

9th Creditor's name and address
Who owes on this account?
What kind of debt is this?
What is the total amount owed?
What was the last date you paid
anything on this debt?
If there is collection activity,
what stage is it at?

10th Creditor's name and address
Who owes on this account?
What kind of debt is this?
What is the total amount owed?
What was the last date you paid
anything on this debt?
If there is collection activity,
what stage is it at?
What is the total of all other unsecured debt that you have not been able to fit in above? (Please, just additional debt, not debt you've already accounted for.)

"Continuation Sheet:" Detail any additional creditor, account, debtor, last pay date, type of debt and collection activity here.
Please take some time to write down details about how you got into financial trouble, when your situation began to get bad and why. Did you begin to use credit cards to try to pay for necessities (food, clothing, shelter), or to make payments on other debts? Did you lose work, go through a separation from a partner? What things contributed to you getting behind on your debts?
Since going through what you just described, what steps have you taken to bring your financial situation around? How much success, if any, have you had? What else should we know about your situation?
We have time stamped this form and issued an order number as shown below. Please write this date and time down, it will identify your form for us, particularly if you do not include your name.

Submission    Return to top  

©Financial Firebird Corporation (1-800-351-3301),
Mory Brenner, Esq.
This page created by John P. Green, Esq., using the excellent shareware html editor, "FlexSite" ©, from Lincoln Beach Software, Inc.®. Please e-mail your comments or suggestions, and, to those who have given me advice and feedback on this page, "Thanks!," John P. Green Last modified 9/09/00 at 11:50 PM

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