QUESTIONNAIRE

This is an attempt to collect a debt, and any information obtained will be used for that purpose.

Your Information (a section for your husband/wife follows)

1.
2.

,
a. Do you or ?
How much is your rent or mortgage payment?
b. Landlord or Mortgage Company Name, Address & Phone Number:
3.
4.
5. Driver's License or State ID Number:
Indentification information:
a.
b. :
c. :
d. :
6. Social Security Number:
7. Name of employer:
a. Address:

b. Phone:
c. Hourly wage or monthly salary: Are you or ?
d. Your pay period is: Next pay date:
e. Average Take Home Pay:
1. Are you currently being garnished? . How much?
2. Is child support deducted from your check? . How much?
f. Tips or Commissions:
8.
9.
10. If "other", explain:
11. Number of Minor Children living with you:
Do you pay child support?
If so, ?
12. Name, address & phone number of your nearest living relative not living with you:
If not married, skip to Question 19.

The following questions are about your SPOUSE (Husband or Wife):
13.
14.

,
:
15.
16. Husband/Wife's Driver's License or State ID Number:
Husband/Wife's Indentification information:
a.
b. :
c. :
d. :
17. Husband/Wife's Social Security Number:
18. Husband/Wife's employer:
a. Address:

b. Phone:
c. Hourly wage or monthly salary: Are you or ?
d. Your pay period is: Next pay date:
e. Average Take Home Pay:
f. Tips or Commissions:
g. Income from other sources:

19. Do you have any checking, savings or other bank accounts? If so list bank or credit union's name & address:
20. Do you own any cars, vehicles, motorcycles, recreational vehicles or collections? If so describe:
21. Are you willing to make ?
22. Proposed : ?
23. :
Under the penalties of perjury, I state that I have read the foregoing answers and that the answers are true and correct to the best of my knowledge and belief.

By clicking the Submit button, below, I agree to the above statement.