Middlebrooks Shapiro Individual Questionnaire

1
What is your full, legal name?* This field is required.As it appears on your social security card.
Prefix
First Name
Middle Name
Last Name
Suffix
2
Do you have any former, or maiden, names?
YESNO
3
Former or maiden nameOnly include names used in the last six years.
4
What is your date of birth?
Month
Day
Year
5
What is your email address?
example@example.com
6
What is your phone number
Area Code
Phone Number
7
What is your current address?
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Please Select
Please Select
United States
Afghanistan
Albania
Algeria
American Samoa
Andorra
Angola
Anguilla
Antigua and Barbuda
Argentina
Armenia
Aruba
Australia
Austria
Azerbaijan
The Bahamas
Bahrain
Bangladesh
Barbados
Belarus
Belgium
Belize
Benin
Bermuda
Bhutan
Bolivia
Bosnia and Herzegovina
Botswana
Brazil
Brunei
Bulgaria
Burkina Faso
Burundi
Cambodia
Cameroon
Canada
Cape Verde
Cayman Islands
Central African Republic
Chad
Chile
China
Christmas Island
Cocos (Keeling) Islands
Colombia
Comoros
Congo
Cook Islands
Costa Rica
Cote d'Ivoire
Croatia
Cuba
Curacao
Cyprus
Czech Republic
Democratic Republic of the Congo
Denmark
Djibouti
Dominica
Dominican Republic
Ecuador
Egypt
El Salvador
Equatorial Guinea
Eritrea
Estonia
Ethiopia
Falkland Islands
Faroe Islands
Fiji
Finland
France
French Polynesia
Gabon
The Gambia
Georgia
Germany
Ghana
Gibraltar
Greece
Greenland
Grenada
Guadeloupe
Guam
Guatemala
Guernsey
Guinea
Guinea-Bissau
Guyana
Haiti
Honduras
Hong Kong
Hungary
Iceland
India
Indonesia
Iran
Iraq
Ireland
Israel
Italy
Jamaica
Japan
Jersey
Jordan
Kazakhstan
Kenya
Kiribati
North Korea
South Korea
Kosovo
Kuwait
Kyrgyzstan
Laos
Latvia
Lebanon
Lesotho
Liberia
Libya
Liechtenstein
Lithuania
Luxembourg
Macau
Macedonia
Madagascar
Malawi
Malaysia
Maldives
Mali
Malta
Marshall Islands
Martinique
Mauritania
Mauritius
Mayotte
Mexico
Micronesia
Moldova
Monaco
Mongolia
Montenegro
Montserrat
Morocco
Mozambique
Myanmar
Nagorno-Karabakh
Namibia
Nauru
Nepal
Netherlands
Netherlands Antilles
New Caledonia
New Zealand
Nicaragua
Niger
Nigeria
Niue
Norfolk Island
Turkish Republic of Northern Cyprus
Northern Mariana
Norway
Oman
Pakistan
Palau
Palestine
Panama
Papua New Guinea
Paraguay
Peru
Philippines
Pitcairn Islands
Poland
Portugal
Puerto Rico
Qatar
Republic of the Congo
Romania
Russia
Rwanda
Saint Barthelemy
Saint Helena
Saint Kitts and Nevis
Saint Lucia
Saint Martin
Saint Pierre and Miquelon
Saint Vincent and the Grenadines
Samoa
San Marino
Sao Tome and Principe
Saudi Arabia
Senegal
Serbia
Seychelles
Sierra Leone
Singapore
Slovakia
Slovenia
Solomon Islands
Somalia
Somaliland
South Africa
South Ossetia
South Sudan
Spain
Sri Lanka
Sudan
Suriname
Svalbard
eSwatini
Sweden
Switzerland
Syria
Taiwan
Tajikistan
Tanzania
Thailand
Timor-Leste
Togo
Tokelau
Tonga
Transnistria Pridnestrovie
Trinidad and Tobago
Tristan da Cunha
Tunisia
Turkey
Turkmenistan
Turks and Caicos Islands
Tuvalu
Uganda
Ukraine
United Arab Emirates
United Kingdom
Uruguay
Uzbekistan
Vanuatu
Vatican City
Venezuela
Vietnam
British Virgin Islands
Isle of Man
US Virgin Islands
Wallis and Futuna
Western Sahara
Yemen
Zambia
Zimbabwe
Other
Country
8
What are the dates of your occupancy at this address?

From Date to Date
9
Are there any prior addresses you've lived at in the last two years?
YESNO
10
Please list your prior addresses from the last two years.

Street Address     Address Line 2     City     State     Zip

Date of Occupancy:    Date    to    Date

Street Address     Address Line 2     City     State     Zip

Date of Occupancy:    Date    to    Date
11
Is your mailing address different from the address provided?
YESNO
12
Mailing Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Please Select
Please Select
United States
Afghanistan
Albania
Algeria
American Samoa
Andorra
Angola
Anguilla
Antigua and Barbuda
Argentina
Armenia
Aruba
Australia
Austria
Azerbaijan
The Bahamas
Bahrain
Bangladesh
Barbados
Belarus
Belgium
Belize
Benin
Bermuda
Bhutan
Bolivia
Bosnia and Herzegovina
Botswana
Brazil
Brunei
Bulgaria
Burkina Faso
Burundi
Cambodia
Cameroon
Canada
Cape Verde
Cayman Islands
Central African Republic
Chad
Chile
China
Christmas Island
Cocos (Keeling) Islands
Colombia
Comoros
Congo
Cook Islands
Costa Rica
Cote d'Ivoire
Croatia
Cuba
Curacao
Cyprus
Czech Republic
Democratic Republic of the Congo
Denmark
Djibouti
Dominica
Dominican Republic
Ecuador
Egypt
El Salvador
Equatorial Guinea
Eritrea
Estonia
Ethiopia
Falkland Islands
Faroe Islands
Fiji
Finland
France
French Polynesia
Gabon
The Gambia
Georgia
Germany
Ghana
Gibraltar
Greece
Greenland
Grenada
Guadeloupe
Guam
Guatemala
Guernsey
Guinea
Guinea-Bissau
Guyana
Haiti
Honduras
Hong Kong
Hungary
Iceland
India
Indonesia
Iran
Iraq
Ireland
Israel
Italy
Jamaica
Japan
Jersey
Jordan
Kazakhstan
Kenya
Kiribati
North Korea
South Korea
Kosovo
Kuwait
Kyrgyzstan
Laos
Latvia
Lebanon
Lesotho
Liberia
Libya
Liechtenstein
Lithuania
Luxembourg
Macau
Macedonia
Madagascar
Malawi
Malaysia
Maldives
Mali
Malta
Marshall Islands
Martinique
Mauritania
Mauritius
Mayotte
Mexico
Micronesia
Moldova
Monaco
Mongolia
Montenegro
Montserrat
Morocco
Mozambique
Myanmar
Nagorno-Karabakh
Namibia
Nauru
Nepal
Netherlands
Netherlands Antilles
New Caledonia
New Zealand
Nicaragua
Niger
Nigeria
Niue
Norfolk Island
Turkish Republic of Northern Cyprus
Northern Mariana
Norway
Oman
Pakistan
Palau
Palestine
Panama
Papua New Guinea
Paraguay
Peru
Philippines
Pitcairn Islands
Poland
Portugal
Puerto Rico
Qatar
Republic of the Congo
Romania
Russia
Rwanda
Saint Barthelemy
Saint Helena
Saint Kitts and Nevis
Saint Lucia
Saint Martin
Saint Pierre and Miquelon
Saint Vincent and the Grenadines
Samoa
San Marino
Sao Tome and Principe
Saudi Arabia
Senegal
Serbia
Seychelles
Sierra Leone
Singapore
Slovakia
Slovenia
Solomon Islands
Somalia
Somaliland
South Africa
South Ossetia
South Sudan
Spain
Sri Lanka
Sudan
Suriname
Svalbard
eSwatini
Sweden
Switzerland
Syria
Taiwan
Tajikistan
Tanzania
Thailand
Timor-Leste
Togo
Tokelau
Tonga
Transnistria Pridnestrovie
Trinidad and Tobago
Tristan da Cunha
Tunisia
Turkey
Turkmenistan
Turks and Caicos Islands
Tuvalu
Uganda
Ukraine
United Arab Emirates
United Kingdom
Uruguay
Uzbekistan
Vanuatu
Vatican City
Venezuela
Vietnam
British Virgin Islands
Isle of Man
US Virgin Islands
Wallis and Futuna
Western Sahara
Yemen
Zambia
Zimbabwe
Other
Country
13
Are you a married couple who is filing jointly?If yes, you'll enter information about your spouse (the "joint debtor") in the next section.
YESNO
14
What is the joint debtor's full, legal name?* This field is required.As it appears on their social security card.
Prefix
First Name
Middle Name
Last Name
Suffix
15
Does the joint debtor have any former, or maiden, names?
YESNO
16
Joint debtor's former or maiden nameOnly include names used in the last six years.
17
What is the joint debtor's date of birth?
Month
Day
Year
18
What is the joint debtor's email address?
example@example.com
19
What is the joint debtor's phone number?
Area Code
Phone Number
20
Is the joint debtor's address different from the address you provided in Section 1?
YESNO
21
Joint debtor's address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Please Select
Please Select
United States
Afghanistan
Albania
Algeria
American Samoa
Andorra
Angola
Anguilla
Antigua and Barbuda
Argentina
Armenia
Aruba
Australia
Austria
Azerbaijan
The Bahamas
Bahrain
Bangladesh
Barbados
Belarus
Belgium
Belize
Benin
Bermuda
Bhutan
Bolivia
Bosnia and Herzegovina
Botswana
Brazil
Brunei
Bulgaria
Burkina Faso
Burundi
Cambodia
Cameroon
Canada
Cape Verde
Cayman Islands
Central African Republic
Chad
Chile
China
Christmas Island
Cocos (Keeling) Islands
Colombia
Comoros
Congo
Cook Islands
Costa Rica
Cote d'Ivoire
Croatia
Cuba
Curacao
Cyprus
Czech Republic
Democratic Republic of the Congo
Denmark
Djibouti
Dominica
Dominican Republic
Ecuador
Egypt
El Salvador
Equatorial Guinea
Eritrea
Estonia
Ethiopia
Falkland Islands
Faroe Islands
Fiji
Finland
France
French Polynesia
Gabon
The Gambia
Georgia
Germany
Ghana
Gibraltar
Greece
Greenland
Grenada
Guadeloupe
Guam
Guatemala
Guernsey
Guinea
Guinea-Bissau
Guyana
Haiti
Honduras
Hong Kong
Hungary
Iceland
India
Indonesia
Iran
Iraq
Ireland
Israel
Italy
Jamaica
Japan
Jersey
Jordan
Kazakhstan
Kenya
Kiribati
North Korea
South Korea
Kosovo
Kuwait
Kyrgyzstan
Laos
Latvia
Lebanon
Lesotho
Liberia
Libya
Liechtenstein
Lithuania
Luxembourg
Macau
Macedonia
Madagascar
Malawi
Malaysia
Maldives
Mali
Malta
Marshall Islands
Martinique
Mauritania
Mauritius
Mayotte
Mexico
Micronesia
Moldova
Monaco
Mongolia
Montenegro
Montserrat
Morocco
Mozambique
Myanmar
Nagorno-Karabakh
Namibia
Nauru
Nepal
Netherlands
Netherlands Antilles
New Caledonia
New Zealand
Nicaragua
Niger
Nigeria
Niue
Norfolk Island
Turkish Republic of Northern Cyprus
Northern Mariana
Norway
Oman
Pakistan
Palau
Palestine
Panama
Papua New Guinea
Paraguay
Peru
Philippines
Pitcairn Islands
Poland
Portugal
Puerto Rico
Qatar
Republic of the Congo
Romania
Russia
Rwanda
Saint Barthelemy
Saint Helena
Saint Kitts and Nevis
Saint Lucia
Saint Martin
Saint Pierre and Miquelon
Saint Vincent and the Grenadines
Samoa
San Marino
Sao Tome and Principe
Saudi Arabia
Senegal
Serbia
Seychelles
Sierra Leone
Singapore
Slovakia
Slovenia
Solomon Islands
Somalia
Somaliland
South Africa
South Ossetia
South Sudan
Spain
Sri Lanka
Sudan
Suriname
Svalbard
eSwatini
Sweden
Switzerland
Syria
Taiwan
Tajikistan
Tanzania
Thailand
Timor-Leste
Togo
Tokelau
Tonga
Transnistria Pridnestrovie
Trinidad and Tobago
Tristan da Cunha
Tunisia
Turkey
Turkmenistan
Turks and Caicos Islands
Tuvalu
Uganda
Ukraine
United Arab Emirates
United Kingdom
Uruguay
Uzbekistan
Vanuatu
Vatican City
Venezuela
Vietnam
British Virgin Islands
Isle of Man
US Virgin Islands
Wallis and Futuna
Western Sahara
Yemen
Zambia
Zimbabwe
Other
Country
22
Do you reside in a community property state, commonwealth, or territory, or have you in the past six years?If you've lived in Alaska, Arizona, California, Idaho, Louisiana, Nevada, New Mexico, Puerto Rico, Texas, Washington, or Wisconsin in the past six years, click Yes.
YESNO
23
Did any spouse or former spouse reside with you at that time?
YESNO
24
What is the name of your spouse or former spouse who resided with you?
25
Has a bankruptcy case been filed by you or against you in the last 6 years?
YESNO
26
Please provide more information on the case(s).
27
Are there currently any bankruptcy cases pending against you, your business, your spouse, or your spouse’s business?
YESNO
28
Please provide more information on the case(s).
29
Do you own any real estate?This includes any real estate which you own or are a joint owner of, even if you still owe money on the property. We'll ask about personal property in the next section.
YESNO
30
Real Estate Property OwnershipFill out this form for each property you or the joint debtor own or jointly own, even if you still owe money on the property. Please provide the address and description of the real estate property, whether it is owned by the Husband, Wife, Jointly, or as Community Property, the percentage or amount of ownership, and whether you intend to Keep or Surrender the property. We'll ask about mortgages, home equity loans, and liens on the properties in the next quesiton.
31
Are there any mortgages, home equity loans, or liens on any of these properties?
YESNO
32
Mortgages, Home Equity Loans, and LiensFill out this form for each mortgage, home equity loan, and lien. Please provide the address of the property, the type of loan (mortgage, home equity loan, or lien), and lender and loan information.
33
Do you have any cash on hand?
YESNO
34
Cash on HandPlease indicate whether the cash on hand is owned by the Husband, Wife, Jointly, or as Community property.
35
Do you have any checking accounts?
YESNO
36
Checking AccountsPlease indicate whether the account is owned by the Husband, Wife, Jointly, or as Community property.
37
Do you have any savings accounts?
YESNO
38
Savings AccountsPlease indicate whether the account is owned by the Husband, Wife, Jointly, or as Community property.
39
Do you have any Certificates of Deposit?
YESNO
40
Certificates of DepositPlease indicate whether the Certificate of Deposit is owned by the Husband, Wife, Jointly, or as Community property.
41
Do you have any other bank accounts?
YESNO
42
Other Bank AccountsPlease indicate whether the account is owned by the Husband, Wife, Jointly, or as Community property.
43
Did you have any bank accounts that were closed in the past year?
YESNO
44
Closed Bank AccountsPlease indicate whether the account was owned by the Husband, Wife, Jointly, or as Community property.
45
Do you have any security deposits held by utility companies or landlords?
YESNO
46
Security DepositsPlease include a description of the security deposit and where it is located; whether the security deposit was made by the Husband, Wife, Jointly, or as Community property; and the current market value of the deposit.
47
Do you have any household goods (i.e., furniture, appliances, including audio, video, and computer equipment)?
YESNO
48
Household GoodsPlease include a description of the property and where it is located; whether the property is owned by the Husband, Wife, Jointly, or as Community property; and the current market value/resale value.
49
Do you have any books, pictures, art objects, or collectibles?
YESNO
50
Books, pictures, art objects, collectibles Please include a description of the property and where it is located; whether the property is owned by the Husband, Wife, Jointly, or as Community property; and the current market value/resale value.
51
Do you have any clothing?
YESNO
52
Clothing Please include a description of the property and where it is located; whether the property is owned by the Husband, Wife, Jointly, or as Community property; and the current market value/resale value.
53
Do you have any furs or jewelry?
YESNO
54
Furs and Jewelry Please include a description of the property and where it is located; whether the property is owned by the Husband, Wife, Jointly, or as Community property; and the current market value/resale value.
55
Do you have any firearms or sports, photographic, or hobby equipment?
YESNO
56
Firearms and Sports, Photographic, and Hobby Equipment Please include a description of the property and where it is located; whether the property is owned by the Husband, Wife, Jointly, or as Community property; and the current market value/resale value.
57
Do you have any safe deposit boxes?
YESNO
58
Safe Deposit Boxes Please include a description of the contents of the safe deposit box and where it is located; whether the property is owned by the Husband, Wife, Jointly, or as Community property; and the current market value/resale value.
59
Do you have any interest in insurance policies?
YESNO
60
Interest in Insurance Policies Please include a description of the interest in the policy, including whether it is whole or term; whether the property is owned by the Husband, Wife, Jointly, or as Community property; and the cash value.
61
Do you have any annuities?
YESNO
62
Annuities Please include a description of the property and where it is located; whether the property is owned by the Husband, Wife, Jointly, or as Community property; and the current market value.
63
Do you have any interests in pension, IRA, 401(k) or profit sharing plans?
YESNO
64
Interests in Pension, IRA, 401(k) and Profit Sharing Plans Please include a description of the property and where it is located; if you have taken any loans, the amount; whether the property is owned by the Husband, Wife, Jointly, or as Community property; and the current market value.
65
Do you have any stocks or bonds?
YESNO
66
Stocks and Bonds Please include a description of the property and where it is located; whether the property is owned by the Husband, Wife, Jointly, or as Community property; and the current market value.
67
Do you have interest in any businesses?
YESNO
68
Interest in Businesses Please include a description of the property and where it is located; whether the property is owned by the Husband, Wife, Jointly, or as Community property; and the current market value.
69
Do you have an interest in any partnerships or joint ventures?
YESNO
70
Interests in Partnerships/Joint VenturesPlease include a description of the property and where it is located; whether the property is owned by the Husband, Wife, Jointly, or as Community property; and the current market value.
71
Do you have any accounts receivable?
YESNO
72
Accounts ReceivablePlease include a description of the property and where it is located; whether the property is owned by the Husband, Wife, Jointly, or as Community property; and the current market value.
73
Do you have any alimony or family support to which you are entitled?
YESNO
74
Alimony/Family Support Please include a description of the support; whether the Husband or Wife is entitled to the support; and the amount.
75
Do you have any other liquidated debts owed to you, including tax refunds?
YESNO
76
Liquidated Debts/Tax Refunds Please include a description of the property and where it is located; whether the property is owned by the Husband, Wife, Jointly, or as Community property; and the current market value.
77
Do you have any life estates or equitable or future interests?
YESNO
78
Life Estates/Equitable or Future InterestsPlease include a description of the property and where it is located; whether the property is owned by the Husband, Wife, Jointly, or as Community property; and the current market value.
79
Do you have any interests in the estate of a decedent, or life insurance plan or trust?
YESNO
80
Interests in Estate of Decedent/Life Insurance Plan or TrustPlease include a description of the property and where it is located; whether the property is owned by the Husband, Wife, Jointly, or as Community property; and the current market value.
81
Do you have any patents, copyrights, other intellectual property, licenses, or franchises?
YESNO
82
Intellectual Property/Licenses/Franchises Please include a description of the property and where it is located; whether the property is owned by the Husband, Wife, Jointly, or as Community property; and the current market value.
83
Do you have any automobiles, trucks, or trailers?
YESNO
84
Automobiles/Trucks/Trailers Please include the year, make, model, and mileage of each vehicle; whether the vehicle is owned by the Husband, Wife, Jointly, or as Community property; the current market value; and, if the vehicle is financed or leased, whether you intend to Keep the vehicle or Surrender it back to the lender.
85
Do you have any boats, motors, or accessories?
YESNO
86
Boats, Motors, and Accessories Please include the year, make, model, and size of each boat, or a description of the accessory; whether the property is owned by the Husband, Wife, Jointly, or as Community property; and the current market value.
87
Do you have any aircraft or accessories?
YESNO
88
Aircraft and AccessoriesPlease include a description of the property and where it is located; whether the property is owned by the Husband, Wife, Jointly, or as Community property; and the current market value.
89
Do you have any office equipment or supplies?
YESNO
90
Office Equipment and Supplies Please include a description of the property and where it is located; whether the property is owned by the Husband, Wife, Jointly, or as Community property; and the current market value.
91
Do you have any machinery for business?
YESNO
92
Machinery for BusinessPlease include a description of the property and where it is located; whether the property is owned by the Husband, Wife, Jointly, or as Community property; and the current market value.
93
Do you have any inventory?
YESNO
94
InventoryPlease include a description of the property and where it is located; whether the property is owned by the Husband, Wife, Jointly, or as Community property; and the current market value.
95
Do you have any animals, crops, or farming equipment?
YESNO
96
Animals/Crops/Farming Equipment Please include a description of the property and where it is located; whether the property is owned by the Husband, Wife, Jointly, or as Community property; and the current market value.
97
Do you have any property held or controlled for another person?
YESNO
98
Property Held or Controlled for Another Person Please include a description of the property and where it is located; the name and address of the owner, whether the property is held by the Husband, Wife, Jointly, or as Community property; and the current market value.
99
Have you owned any real estate in the last ten years?
YESNO
100
Please provide more information about the real estate you've owned in the last ten years.
Huge
Large
Normal
Small
Ok
Ok
101
Has any property been repossessed or sold at a foreclosure sale in the last year?
YESNO
102
Please provide more information about the property that has been repossessed or sold at a foreclosure sale in the last year.
Huge
Large
Normal
Small
Ok
Ok
103
Have any of your bank accounts been levied upon in the last year?
YESNO
104
Please provide more information about bank accounts that have been levied upon in the last year.
Huge
Large
Normal
Small
Ok
Ok
105
Have your wages been garnished in the last year?
YESNO
106
Please provide more information about wages garnished in the last year.
Huge
Large
Normal
Small
Ok
Ok
107
Has any other property been seized or attached in the last year?
YESNO
108
Please provide more information about any other property that has been seized or attached in the last year.
Huge
Large
Normal
Small
Ok
Ok
109
Has any property been in the hands of a custodian, receiver or court-appointed official in the last year?
YESNO
110
Please provide more information about any property that has been in the hands of a custodian, receiver or court-appointed official in the last year.
Huge
Large
Normal
Small
Ok
Ok
111
Has any creditor, including a bank, made setoffs against a debt or deposit of yours in the last 90 days?
YESNO
112
Please provide more information about any setoffs against a debt or deposit of yours made by a creditor, including a bank, in the last 90 days.
Huge
Large
Normal
Small
Ok
Ok
113
Have you had any losses from fire, theft, gambling or other casualty in the last year?
YESNO
114
Please provide more information about any losses you've had from fire, theft, gambling or other casualty in the last year.
Huge
Large
Normal
Small
Ok
Ok
115
Have you made any charitable contributions of over $200 in the last year?
YESNO
116
Please provide more information about any charitable contributions of over $200 you've made in the last year.
Huge
Large
Normal
Small
Ok
Ok
117
Have you given any gifts of over $200 in the last year?
YESNO
118
Please provide more information about any gifts of over $200 you've given in the last year.
Huge
Large
Normal
Small
Ok
Ok
119
Do you have any Secured Debts (mortgage, home loan, auto loan, auto lease)?
YESNO
120
Secured Debts (mortgage, home loan, auto loan, auto lease) List all Secured Debts in your or the joint debtor's name.
121
Please upload any related documentation regarding your Secured Debts.
Drag and drop files here
Select files to upload
Max. file size: 10.6MB
Cancelof
122
Do you have any Priority Debts (student loans, unpaid taxes, unpaid utility bills)?
YESNO
123
Priority Debts (student loans, unpaid taxes, unpaid utility bills)List all Priority Debts in your or the joint debtor's name.
124
Please upload any related documentation regarding your Priority Debts.
Drag and drop files here
Select files to upload
Max. file size: 10.6MB
Cancelof
125
Do you have any Non-Priority Debts (credit cards, store credit, personal loans)?
YESNO
126
Non-Priority Debts (credit cards, store credit, personal loans)List all Non-Priority Debts in your or the joint debtor's name.
127
Please upload any related documentation regarding your Priority Debts.
Drag and drop files here
Select files to upload
Max. file size: 10.6MB
Cancelof
128
Would you like us to run a credit report? (Fee $33.00 individual; $66.00 couple) (Fee $33.00 individual; $66.00 couple) You can also access a free copy of your credit report from www.annualcreditreport.com
YESNO
129
I, the debtor, authorize Middlebrooks Shapiro to run a credit report for me.Please sign the box below.
Clear
130
I, the joint debtor, authorize Middlebrooks Shapiro to run a credit report for me.Please sign the box below.
Clear
131
Are you behind on any mortgage payments?
YESNO
132
By what amount?
133
Are you behind on any car payments?
YESNO
134
By what amount?
135
Have you used your credit cards in the last 90 days?
YESNO
136
What types of items did you purchase and how much did you spend?
137
Have you made any payments of over $600 to creditors in the last 90 days?
YESNO
138
Please upload proof of payment including amount, date and to whom payment was made.
Drag and drop files here
Select files to upload
Max. file size: 10.6MB
Cancelof
139
Have you made any payments to relatives, business partners or corporations to whom you owe money in the last 90 days?
YESNO
140
Please upload proof of payment including amount, date and to whom payment was made.
Drag and drop files here
Select files to upload
Max. file size: 10.6MB
Cancelof
141
Have you received any law suits in relation to debts you owe?
YESNO
142
Please list the law suits in relation to debts you owe.
143
Has anyone co-signed on a loan for you?
YESNO
144
Please list the loans.
145
Did you co-sign any loans for anyone else?
YESNO
146
Please list the loans.
147
Do you pay domestic/child support?
YESNO
148
Please list the name(s) and address(es) to whom these payments are made.
149
Are you behind on any payments?
YESNO
150
Please list the amount.
151
Are you currently a party to any leases or contracts?This includes residential, car and business leases, and service or business contracts.
YESNO
152
Please list the leases and contracts.
153
What is your marital status?
Married
Single
Divorced
Separated
Widowed
Select one.
154
List all your dependents, their ages, and their relationship to you.
155
What is your occupation?
156
What is the name and address of your employer?
Name
Street Address
City
State / Province
Postal / Zip Code
Please Select
Please Select
United States
Afghanistan
Albania
Algeria
American Samoa
Andorra
Angola
Anguilla
Antigua and Barbuda
Argentina
Armenia
Aruba
Australia
Austria
Azerbaijan
The Bahamas
Bahrain
Bangladesh
Barbados
Belarus
Belgium
Belize
Benin
Bermuda
Bhutan
Bolivia
Bosnia and Herzegovina
Botswana
Brazil
Brunei
Bulgaria
Burkina Faso
Burundi
Cambodia
Cameroon
Canada
Cape Verde
Cayman Islands
Central African Republic
Chad
Chile
China
Christmas Island
Cocos (Keeling) Islands
Colombia
Comoros
Congo
Cook Islands
Costa Rica
Cote d'Ivoire
Croatia
Cuba
Curacao
Cyprus
Czech Republic
Democratic Republic of the Congo
Denmark
Djibouti
Dominica
Dominican Republic
Ecuador
Egypt
El Salvador
Equatorial Guinea
Eritrea
Estonia
Ethiopia
Falkland Islands
Faroe Islands
Fiji
Finland
France
French Polynesia
Gabon
The Gambia
Georgia
Germany
Ghana
Gibraltar
Greece
Greenland
Grenada
Guadeloupe
Guam
Guatemala
Guernsey
Guinea
Guinea-Bissau
Guyana
Haiti
Honduras
Hong Kong
Hungary
Iceland
India
Indonesia
Iran
Iraq
Ireland
Israel
Italy
Jamaica
Japan
Jersey
Jordan
Kazakhstan
Kenya
Kiribati
North Korea
South Korea
Kosovo
Kuwait
Kyrgyzstan
Laos
Latvia
Lebanon
Lesotho
Liberia
Libya
Liechtenstein
Lithuania
Luxembourg
Macau
Macedonia
Madagascar
Malawi
Malaysia
Maldives
Mali
Malta
Marshall Islands
Martinique
Mauritania
Mauritius
Mayotte
Mexico
Micronesia
Moldova
Monaco
Mongolia
Montenegro
Montserrat
Morocco
Mozambique
Myanmar
Nagorno-Karabakh
Namibia
Nauru
Nepal
Netherlands
Netherlands Antilles
New Caledonia
New Zealand
Nicaragua
Niger
Nigeria
Niue
Norfolk Island
Turkish Republic of Northern Cyprus
Northern Mariana
Norway
Oman
Pakistan
Palau
Palestine
Panama
Papua New Guinea
Paraguay
Peru
Philippines
Pitcairn Islands
Poland
Portugal
Puerto Rico
Qatar
Republic of the Congo
Romania
Russia
Rwanda
Saint Barthelemy
Saint Helena
Saint Kitts and Nevis
Saint Lucia
Saint Martin
Saint Pierre and Miquelon
Saint Vincent and the Grenadines
Samoa
San Marino
Sao Tome and Principe
Saudi Arabia
Senegal
Serbia
Seychelles
Sierra Leone
Singapore
Slovakia
Slovenia
Solomon Islands
Somalia
Somaliland
South Africa
South Ossetia
South Sudan
Spain
Sri Lanka
Sudan
Suriname
Svalbard
eSwatini
Sweden
Switzerland
Syria
Taiwan
Tajikistan
Tanzania
Thailand
Timor-Leste
Togo
Tokelau
Tonga
Transnistria Pridnestrovie
Trinidad and Tobago
Tristan da Cunha
Tunisia
Turkey
Turkmenistan
Turks and Caicos Islands
Tuvalu
Uganda
Ukraine
United Arab Emirates
United Kingdom
Uruguay
Uzbekistan
Vanuatu
Vatican City
Venezuela
Vietnam
British Virgin Islands
Isle of Man
US Virgin Islands
Wallis and Futuna
Western Sahara
Yemen
Zambia
Zimbabwe
Other
Country
157
How long have you been employed there?
158
What is the gross amount of your paycheck? This is the amount before taxes and other deductions are taken out.
159
How often are you paid?
Once a month
Every two weeks
Twice and month
Once a week
160
Do you receive income from business operations outside of your regular paycheck listed above?
YESNO
161
What is the business, and how much do you receive per month?
162
Do you receive any income from real estate property?
YESNO
163
How much do you receive per month?
164
Do you receive any interest or dividends?
YESNO
165
How much do you receive per month?
166
Do you receive any alimony or family support payments, either for your use or for the care of your dependents?
YESNO
167
How much do you receive per month?
168
Do you receive any social security or other forms of monetary government assistance?
YESNO
169
How much do you receive per month?
170
Do you receive any retirement or pension money?
YESNO
171
How much do you receive per month?
172
Do you receive any contributions from family members?
YESNO
173
How much do you receive per month?
174
Do you have any other sources of income not listed?
YESNO
175
Please provide more information about your other sources of income.
Huge
Large
Normal
Small
Ok
Ok
176
Are you expecting any increase or decrease in salary of more than 10% next year?
YESNO
177
Please explain.
Huge
Large
Normal
Small
Ok
Ok
178
What is the joint debtor's marital status?
Married
Single
Divorced
Separated
Widowed
Select one.
179
List all the joint debtor's dependents, their ages, and their relationship to the joint debtor.
180
What is the joint debtor's occupation?
181
What is the name and address of the joint debtor's employer?
Name
Street Address
City
State / Province
Postal / Zip Code
Please Select
Please Select
United States
Afghanistan
Albania
Algeria
American Samoa
Andorra
Angola
Anguilla
Antigua and Barbuda
Argentina
Armenia
Aruba
Australia
Austria
Azerbaijan
The Bahamas
Bahrain
Bangladesh
Barbados
Belarus
Belgium
Belize
Benin
Bermuda
Bhutan
Bolivia
Bosnia and Herzegovina
Botswana
Brazil
Brunei
Bulgaria
Burkina Faso
Burundi
Cambodia
Cameroon
Canada
Cape Verde
Cayman Islands
Central African Republic
Chad
Chile
China
Christmas Island
Cocos (Keeling) Islands
Colombia
Comoros
Congo
Cook Islands
Costa Rica
Cote d'Ivoire
Croatia
Cuba
Curacao
Cyprus
Czech Republic
Democratic Republic of the Congo
Denmark
Djibouti
Dominica
Dominican Republic
Ecuador
Egypt
El Salvador
Equatorial Guinea
Eritrea
Estonia
Ethiopia
Falkland Islands
Faroe Islands
Fiji
Finland
France
French Polynesia
Gabon
The Gambia
Georgia
Germany
Ghana
Gibraltar
Greece
Greenland
Grenada
Guadeloupe
Guam
Guatemala
Guernsey
Guinea
Guinea-Bissau
Guyana
Haiti
Honduras
Hong Kong
Hungary
Iceland
India
Indonesia
Iran
Iraq
Ireland
Israel
Italy
Jamaica
Japan
Jersey
Jordan
Kazakhstan
Kenya
Kiribati
North Korea
South Korea
Kosovo
Kuwait
Kyrgyzstan
Laos
Latvia
Lebanon
Lesotho
Liberia
Libya
Liechtenstein
Lithuania
Luxembourg
Macau
Macedonia
Madagascar
Malawi
Malaysia
Maldives
Mali
Malta
Marshall Islands
Martinique
Mauritania
Mauritius
Mayotte
Mexico
Micronesia
Moldova
Monaco
Mongolia
Montenegro
Montserrat
Morocco
Mozambique
Myanmar
Nagorno-Karabakh
Namibia
Nauru
Nepal
Netherlands
Netherlands Antilles
New Caledonia