Provide Your Info

By the time your debt is referred to our firm, it is delinquent and due in full. Not only are you no longer legally entitled to a monthly or multi-part payment arrangement, it has been our experience that a single lump sum payment to resolve the debt is most beneficial to both you and the creditor. However, we recognize that in some instances such a resolution is simply not possible. In those cases, we need the detailed financial information requested below to properly consider and accurately determine an acceptable payment plan.

GENERAL INFORMATION:	FCKEditorArea
Your Kohn Law Firm account number:
Your full name:
Your residence street address:
City:
State:
Zip Code:
Your telephone number:
Your alternate telephone number:
What is your marital status (Single, Married, Divorced or Separated)?:
If married, how many years have you been married?:
If married, what is your spouse's name:
Number of dependent children under age 18:
MONTHLY EXPENSES:	FCKEditorArea
Do you own or rent your home?:
How much is your mortgage/rent payment? $:
How much are your total utilities (electric, phone, cable, cell phone)? $:
How much are your insurance payments? $:
How much is the payment on your primary car $:
Please list the year, make and model of the car:
How much is the payment on your secondary car $:
Please list the year, make and model of the car:
How much do you pay for gasoline? $:
How much do you pay for food? $:
How much do you pay for medical expenses? $:
How much are your credit card payments? $:
How much do you pay for daycare?:
How much are any other loan payments? $:
How much are any other expenses that you have?:
Please describe what these other expenses are:
MONTHLY INCOME:	FCKEditorArea
Your job title:
Your employer:
Your employer's street address:
Your employer's City:
Your employer's State:
Your employer's Zip Code:
Your work telephone number:
Your employment status (full time, part time, seasonal):
Your gross monthly wage $:
Please list the amount of overtime pay above your normal monthly wage $:
Please list any bonus or commission that you receive in addition to your gross monthly wage $:
Your monthly take home pay $:
Your spouse's job title:
Your spouse's employer:
Your spouse's employer's street address:
Your spouse's employer's City:
Your spouse's employer's State:
Your spouse's employer's Zip Code:
Your spouse's work telephone number:
Your spouse's employment status (full time, part time, seasonal):
Your spouse's gross monthly wage $:
Please list the amount of overtime pay above your spouse's normal monthly wage $:
Please list any bonus or commission that your spouse receives in addition to their gross monthly wage $:
Your spouse's monthly take home pay $:
How much child support do you pay?:
How much child support do you receive?:
Do you receive any of the following needs-based assistance?:	FCKEditorArea
Food Stamps $:
Medical Assistance $:
Supplemental security income $:
Relief funded under public assistance $:
Other (Please describe):
Amount of Other $:
If you are currently being garnished, how much is being garnished from your monthly income? $:
What is the source of this garnishment: (Tax liability, child support, other creditor):
How much do you earn from other sources of income? $:
Please describe this other income source:
ASSETS:	FCKEditorArea
What is the value of your home? $:
How much do you owe on your mortgage? $:
What is the value of any other properties you own? $:
What is the combined average of your checking & savings balance: $:
How much do you have available to purchase on your credit cards? $:
Please list any other assets that you own (stocks, bonds, etc.):
Value of other assets $:
ADDITIONAL COMMENTS/INFORMATION:
NOTICE: This communication is from a debt collector:	FCKEditorArea