Prospect Client Questionnaire

First Name*

Last Name*

Email*

Cell Phone*

Home Phone

Work/Other Phone

Name/Phone of Nearest Friend/Relative Not Living With You

How did you hear about Miller & Miller?*

Have you ever filed a bankruptcy before?

Chapter/Date Filed, if known

Are you a small business owner/operator?

YesNo

Marital Status

Spouse Name

Spouse Address if different from yours

City

State

Zip Code

Your Home Address

City

State

Zip Code

Rent or own

RentOwn

If you own, what is the approximate value of your home?

Date of Purchase/Purchase Price:

Home Mortgage Lender/Amt. Owed

Monthly Mortgage Payment

Behind? If so, how many months

Second Mortgage Lender/Amt Owed

Monthly HELOC or second mort payment amount

Behind? If so, how many months?

Property Tax Amount

Escrowed into mortgage payment or no?

YesNo

HO Insurance

Do you own other real estate (timeshares, rental prop, vacation home)

YesNo

Monthly Health Insurance Expense

Monthly Childcare Expenses

Do you expect any change in income during the next year? If so, please explain:

Type of Car (Year Make Model)

Vehicle 1 Lender/Amount Owed

Vehicle 1 monthly payment amt.

Vehicle 2 Lender/Amount Owed

Vehicle 2 monthly payment amt.

Do you have any other motor vehicles?

YesNo

Do you have a claim or lawsuit against anyone? What might you receive, if you win?

Do you owe any money to the IRS or the State of Wisconsin?

Please list all past due bills to best of your ability (ex.credit cards, medical, loans)

Do you have student loans and if so, amount(s) owed?

Are the student loans

FederalPrivate

Employer/Job Description

Gross Pay (before deductions) per month

Spouse Employer/Job Description

Spouse Gross Pay per month (before deductions)

Other monthly income

YesNo

Source/Amt.

Please list ages/relationships of all dependents you support

Use this area to tell us your biggest concern, fear or question about bankruptcy, if you like.

Thank you so much. See you soon! Remember, if you need to reschedule please call 414.277.7742 so we can make your previously scheduled appointment time available to someone else.

PERSONAL AND CONFIDENTIAL CONTACT INFORMATION