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QUESTIONNAIRE


If you have a printer, please print out the following questionnaire, answer all questions and bring it with you to the Clinic.

                                                                                                                                                                                         

NEW CLIENT QUESTIONNAIRE

(CONSUMER DEBTORS ONLY)

 

Client Name(s): _____________________________________________________

Date:         _________________________


QUESTIONS

YES

NO

Do you own a home?

 

 

   Are your home payments current?

 

 

   Are you property taxes current?

 

 

   Is your home worth more than you owe on it?

 

 

   Are you or your spouse over 65 years of age?

 

 

Do you own a piece of property which is not your home?

 

 

Have you lived in California more than 4 years?

 

 

Do you live alone?

 

 

Do you have any adults who live with you?

 

 

Do you have anything at home worth more than $5,000?

 

 

Do you have anything at home worth more than $1,000?

 

 

Do you rent an offsite storage locker or safe deposit box?

 

 

   Is there anything in the locker or box worth more than $5,000?

 

 

   Is there anything in the locker or box worth more than $1,000?

 

 

Do you own one or more cars?

 

 

   Are you leasing one or more cars?

 

 

      Are you current on the payments?

 

 

   Are you financing one or more cars?

 

 

      Are you current on the payments?

 

 

   Do you have auto insurance on all cars?

 

 

Do you have any life insurance?

 

 

   Does your life insurance have loan or cash surrender value?

 

 

Do you have a pension, IRA, 401k or similar account?

 

 

Do you own any stocks or bonds?

 

 

Does someone owe you money?

 

 

Do you own any patents, copyrights, trademarks?

 

 

   Do you have the right to receive any royalty income?

 

 

Do you receive residual income?

 

 

Are you involved as an owner in any business?

 

 

Are you involved in any trusts?

 

 

Do you own any office furniture or furnishings?

 

 

Do you own any motorcycles, boats, airplanes or anything else

 with a motor?

 

 

Do you own any manufacturing equipment?

 

 

Do you own any show animals?

 

 

Do you own any farming equipment or tools?

 

 

Do you own anything else worth more than $1,000?

 

 

Have you ever used a fake social security or tax ID number?

 

 

Have you ever used more than 1 social security or tax ID number?

 

 

Did you file your federal and State tax returns for last year?

 

 

Do you owe back income taxes?

 

 

Do you owe any other type of taxes?

 

 

In the last 3 years, have you exaggerated or not told the complete truth on a loan or credit card application?

 

 

Have you received cash on a credit card account in the last year?

 

 

Have you used a credit card courtesy check in the last year?

 

 

Have you made a credit card balance transfer in the last year?

 

 

Have you used credit cards more this year than in past years?

 

 

Have you ever filed bankruptcy before?

 

 

Are you involved in any Court, arbitration or other legal proceedings of any type?

 

 

Have you taken money from an employer without permission?

 

 

Have you taken money from a friend or family member without permission?

 

 

Do you have any judgments against you?

 

 

   Do any judgments against you use the word fraud?

 

 

Are you thinking about getting a divorce, now getting a divorce, or been divorced in the last 5 years?

 

 

Do you owe spousal support?

 

 

Do you owe child support?

 

 

Do you owe any money to your ex-spouse?

 

 

Have you ever intentionally injured someone?

 

 

Have you ever intentionally injured someone’s property?

 

 

Do you owe any fines, penalties or sanctions?

 

 

Do you owe any student loans?

 

 

Have you ever caused an accident due to drugs or alcohol?

 

 

Have you ever been convicted of a non-traffic crime?

 

 

Do you owe a restitution debt?

 

 

Do you owe money to a homeowners association?

 

 

Do you owe money to a landlord?

 

 

Do you receive a paycheck?

 

 

   Are you on commission?

 

 

   Do you receive some of your wages in cash?

 

 

Do you think you are disabled?

 

 

Do you get disability payments?

 

 

Have you gotten money from family or friends to help pay for living expenses in the last year?

 

 

Do you get social security?

 

 

Do you have a business?

 

 

Do you get welfare or other government assistance?

 

 

Have you sold anything for more than $500 in the last 2 years?

 

 

Have you given away anything worth more than $200 in the last 7 years?

 

 

Have you repaid a debt to a family member in the last year?

 

 

Do you have a bank account with Wells Fargo Bank?

 

 


     I/We declare, under penalty of perjury under the laws of California, that all of my/our responses are true and correct to the best of our knowledge, information and belief.

 

 

Signed: __________________________  Signed: __________________________


Copyright by The Law Offices of David A. Tilem, All Rights Reserved.
206 N. Jackson Street, Glendale, CA 91206

818-507-6000