Legal Forms

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Leonard & Moore PLLC
274 Merrimon Ave
Asheville, NC 28801

Fax #: (828) 252-6469
Email: [email protected]

FRESH START. NEW BEGINNINGS. FINANCIAL FREEDOM

Full Name

*

First Name

Last Name
Middle
SSN
Date of Birth
Spouse Full Name

First Name

Last Name
Middle
SSN
Date of Birth
Marital Status

Physical Address

*

Street Address
Street Address Line 2
City	State / Province
Postal / Zip Code	Country

Mailing Address

Street Address
Street Address Line 2
City	State / Province
Postal / Zip Code	Country

Not Used

–
Area Code

Phone Number
Phone Number

*

–
Area Code

Phone Number
His Phone

–
Area Code

Phone Number
Her Phone

–
Area Code

Phone Number
Cellular Phone
E-mail Address
Place of Employment (He)
Place of Employment (She)
Local Friend/Relative not Living With You (Emergency Contact)
Name
Relationship To You

Address

Street Address
Street Address Line 2
City	State / Province
Postal / Zip Code	Country

Phone Number

–
Area Code

Phone Number
Have you consulted an attorney prior to this

Yes

No
Name of Attorney
Have you consulted any agency or counseling service concerning your current problems? If so, which one?
How did you select this law firm

Newspaper

Yellow Pages

Iwanna

Radio

Attorney

Friend

Internet

Relative

I am a prior client

Other
State the general nature of your legal matter
Any monies paid to this office, whether filing fees or other, are non-refundable
Interviewed By

Rev. 12/11, 1.12
INFORMATION NECESSARY FOR CHAPTER FILING
His: All sources of money received within the last 6 months (employment, worker’s comp., etc)
Amount Received $
Place(s) of employment this year
Income year to date $
Place(s) of employment last year
Total Income/year $
Place(s) of employment previous year
Total Income/year $
Hers: All sources of money received within the last 6 months (employment, worker’s comp., etc)
Amount Received $
Place(s) of employment this year
Income year to date $
Place(s) of employment last year
Total Income/year $
Place(s) of employment previous year
Total Income/year $
Please bring a current paycheck stub to your appointment.
List income other than from employment or operation of business (such as insurance, workers compensation, Social Security Disability, cach from retirement, prize/contest winning, child support)
Have you repaid loans from or made any gifts to a relative in the past 2 years

Yes

No
Do you have any gambling winnings or loses for the last 6 months

Yes

No
List any property or personal items already returned to a creditor: (Also, list on the debt schedule the creditor information and amount of debt owing at the time items returned)
List any property you want to return to a creditor (List creditor name and amount owed here and on debt schedule)
List any asset (land, car, etc) sold, conveyed or transferred to another name or control within the past two years.
List any creditor, if any, you have paid as much as $600.00 in the last 90 days.
List place of residence and dates resided there for the past two(2) years
Do you pay child support or alimony? If do, provide the payees name, address and telephone number:

Rev. 6/99, 5/00, 8/00, 4/05/, 10/05, 1/07, 12/08, 3/09, 7/09
Average Monthly Cost if Living (Estimate)
Number of People Living in your Home
Mortgage or Rent
Real Estate Taxed or home owners insurance included ?

Yes

No
Utilities
Electricity & Heating $
Water and Sewer $
Telephone $
Garbage Collection $
Cable $
Other $
Home Maintenance (repair and upkeep)
Food
Clothing
Laundry and dry cleaning
Medical and Dental Expenses
Transportation (not including car payments) gas, maintenance, etc
Recreation, clubs, entertainment, Newspaper, magazines, etc
Charitable Contributions (church, donations, etc)
Insurance (not deducted from wages or included in home mortgage payments)
Homeowners or renters
Life
Health
Auto
Taxes (not deducted from wages or included in home mortgage payments)
Home (real estate)
Auto (personal property)
Tobacco addiction
Personal care (haircuts, etc)
Alimony, maintenance and support paid to others
Student Loan Payment
Child Care
Support for additional dependents not living in your home
Lot Rent
Regular expenses from operation of business, profession, or farm – (attach detailed statement)
Other
Please make a brief list of your assets (example: house, timeshare, burial plots, car, boat, personal jewelry, furniture, air conditioners, spots equipment, TV, VCR, books, pictures, and other art objects and other collectibles, stocks, bonds, guns, photographic equipment, appliances, bank accounts, retirement accounts, etc.)
Rev.: 9/98, 8/00, 10/05, 1/07, 12/08, 7/09
List Creditors and Debts
Home, 1st Mortgage
Account Number
Payoff Amount $
Interest Rate
P/I pymnt $
Describe Collateral
Name on Deed

His

Her

Both
His Loan
Her Loan
Joint Loan
Home, 2nd Mortgage
Value of Collateral Payments Behind
Account Number
Payoff Amount $
Interest Rate
P/I pymnt $
Describe Collateral
Name on Deed

His

Her

Both
His Loan
Her Loan
Joint Loan
Vehicle #1, 1st lien
Value of Collateral Payments Behind
Value of Collateral Payments Behind
Account Number
Payoff Amount $
Interest Rate
P/I pymnt $
Describe Collateral
Name on Deed

His

Her

Both
His Loan
Her Loan
Joint Loan
Value of Collateral Payments Behind
Vehicle #2, 1st lien
Phone Number

–
Area Code

Phone Number
Account Number
Payoff Amount $
Date of Purchase

–

Month

–

Day

Year

at

:

Hour

Minutes
Vehicle Type, Make, Year
Interest Rate
Name on Title

His

Her

Both
His Loan
Her Loan
Joint Loan
Value of Collateral Payments Behind
Vehicle #1, 2nd lien
Phone Number

–
Area Code

Phone Number
Account Number
Payoff Amount $
Date of Purchase

–

Month

–

Day

Year

at

:

Hour

Minutes
Vehicle Type, Make, Year
Interest Rate
Name on Title

His

Her

Both
His Loan
Her Loan
Joint Loan
Value of Collateral Payments Behind
List additional motor vehicles in your possession or titled in your name

(Name / Date of Purchase / Value / Ownership – name on title – His/Hers/Joint)
Lease to own contact or rent of property
Account Number
Payoff Amount
Describe Collateral
His
Hers
Joint
Value of Collateral
Rev. 1/01, 08/03, 10/05, 1/07, 12/08, 6/09, 7/09
LIST SECURED DEBTS AND JUDGMENTS (lawsuit)
(Financed or purchase of furniture, appliances, electronics, jewelry, 4-wheelers, etc.)
PUT A STAR BY CREDITORS, if any, from whom you have borrowed or charged, including balance transfers, $600.00 or more in the last 90 days.
Name & Address
Double-click to edit this text…
Phone Number
Account Number
Payoff Amount
Describe Collateral
His/Hers/Both

Remarks
Value
Name & Address
Phone Number
Account Number
Payoff Amount
Describe Collateral
His/Hers/Both

Remarks
Value
Name & Address
Phone Number
Account Number
Payoff Amount
Describe Collateral
His/Hers/Both

Remarks
Value
Name & Address
Phone Number
Account Number
Payoff Amount
Describe Collateral
His/Hers/Both

Remarks
Value
Name & Address
Phone Number
Account Number
Payoff Amount
Describe Collateral
His/Hers/Both

Remarks
Value
Name & Address
Phone Number
Account Number
Payoff Amount
Describe Collateral
His/Hers/Both

Remarks
Value
Name & Address
Phone Number
Account Number
Payoff Amount
Describe Collateral
His/Hers/Both

Remarks
Value
Name & Address
Phone Number
Account Number
Payoff Amount
Describe Collateral
His/Hers/Both

Remarks
Value
LIST UNSECURED DEBTS
(credit card, medical, personal loans and taxes)
PUT A STAR BY CREDITORS, if any, from whom you have borrowed or charged, including balance transfers, $600.00 or more in the last 90 days.
Name and Address
Phone #
Account Number
Payoff Amount
His/Hers/Both

Remarks
LIST UNSECURED DEBTS
(credit card, medical, personal loans and taxes)
PUT A STAR BY CREDITORS, if any, from whom you have borrowed or charged, including balance transfers, $600.00 or more in the last 90 days.
Name and Address
Phone #
Account Number
Payoff Amount
His/Hers/Both

Remarks
LIST UNSECURED DEBTS
(credit card, medical, personal loans and taxes)
PUT A STAR BY CREDITORS, if any, from whom you have borrowed or charged, including balance transfers, $600.00 or more in the last 90 days.
Name and Address
Phone #
Account Number
Payoff Amount
His/Hers/Both

Remarks
LIST UNSECURED DEBTS
(credit card, medical, personal loans and taxes)
PUT A STAR BY CREDITORS, if any, from whom you have borrowed or charged, including balance transfers, $600.00 or more in the last 90 days.
Name and Address
Phone #
Account Number
Payoff Amount
His/Hers/Both

Remarks
LIST UNSECURED DEBTS
(credit card, medical, personal loans and taxes)
PUT A STAR BY CREDITORS, if any, from whom you have borrowed or charged, including balance transfers, $600.00 or more in the last 90 days.
Name and Address
Phone #
Account Number
Payoff Amount
His/Hers/Both

Remarks
LIST UNSECURED DEBTS
(credit card, medical, personal loans and taxes)
PUT A STAR BY CREDITORS, if any, from whom you have borrowed or charged, including balance transfers, $600.00 or more in the last 90 days.
Name and Address
Phone #
Account Number
Payoff Amount
His/Hers/Both

Remarks
LIST UNSECURED DEBTS
(credit card, medical, personal loans and taxes)
PUT A STAR BY CREDITORS, if any, from whom you have borrowed or charged, including balance transfers, $600.00 or more in the last 90 days.
Name and Address
Phone #
Account Number
Payoff Amount
His/Hers/Both

Remarks
LIST UNSECURED DEBTS
(credit card, medical, personal loans and taxes)
PUT A STAR BY CREDITORS, if any, from whom you have borrowed or charged, including balance transfers, $600.00 or more in the last 90 days.
Name and Address
Phone #
Account Number
Payoff Amount
His/Hers/Both

Remarks
LIST UNSECURED DEBTS
(credit card, medical, personal loans and taxes)
PUT A STAR BY CREDITORS, if any, from whom you have borrowed or charged, including balance transfers, $600.00 or more in the last 90 days.
Name and Address
Phone #
Account Number
Payoff Amount
His/Hers/Both

Remarks
LIST UNSECURED DEBTS
(credit card, medical, personal loans and taxes)
PUT A STAR BY CREDITORS, if any, from whom you have borrowed or charged, including balance transfers, $600.00 or more in the last 90 days.
Name and Address
Phone #
Account Number
Payoff Amount
His/Hers/Both

Remarks
LIST UNSECURED DEBTS
(credit card, medical, personal loans and taxes)
PUT A STAR BY CREDITORS, if any, from whom you have borrowed or charged, including balance transfers, $600.00 or more in the last 90 days.
Name and Address
Phone #
Account Number
Payoff Amount
His/Hers/Both

Remarks
LIST UNSECURED DEBTS
(credit card, medical, personal loans and taxes)
PUT A STAR BY CREDITORS, if any, from whom you have borrowed or charged, including balance transfers, $600.00 or more in the last 90 days.
Name and Address
Phone #
Account Number
Payoff Amount
His/Hers/Both

Remarks
LIST UNSECURED DEBTS
(credit card, medical, personal loans and taxes)
PUT A STAR BY CREDITORS, if any, from whom you have borrowed or charged, including balance transfers, $600.00 or more in the last 90 days.
Name and Address
Phone #
Account Number
Payoff Amount
His/Hers/Both

Remarks
LIST UNSECURED DEBTS
(credit card, medical, personal loans and taxes)
PUT A STAR BY CREDITORS, if any, from whom you have borrowed or charged, including balance transfers, $600.00 or more in the last 90 days.
Name and Address
Phone #
Account Number
Payoff Amount
His/Hers/Both

Remarks
LIST UNSECURED DEBTS
(credit card, medical, personal loans and taxes)
PUT A STAR BY CREDITORS, if any, from whom you have borrowed or charged, including balance transfers, $600.00 or more in the last 90 days.
Name and Address
Phone #
Account Number
Payoff Amount
His/Hers/Both

Remarks
Should be Empty:

Leonard & Moore, PLLC

Telephone: (828) 255-0456

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About Leonard & Moore, PLLC