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Are you employed?
YesNo

If yes, How much do you estimate that you gross per month at your job? (Gross, Per Month)
Less than $2000$2000-$3000$3000-$4000$5000-$6000Over $6000

Marital Status
MarriedNever MarriedDivorcedWidowed

If married, is your spouse employed?
YesNo

If yes, how much does he/she make at his/her job? (Gross, Per Month)
less than $2000$2000-$3000$3000-$4000$5000-$6000over $6000

Do you or your spouse have other income from any other source? (Multiple Choice)
UnemploymentChild SupportRetirementSocial SecurityDisabilityother

If yes, how much? (Gross, Per Month)
less than $1000$1000- $2000$2000-$3000$3000-$4000$5000-$6000over $6000

How many dependents do you have?

Do you owe the IRS, or will you owe for any currently unfiled tax returns?
YesNo

Do you have a mortgage payment or a car payment?
YesNo

If yes, are you more than 30 days behind on either payment?
YesNo

Are you being sued by a creditor or anyone else, or have you been sued and lost (if there is already an existing judgment against you)?
YesNo

Approximately how many credit cards/unsecured loans do you have?
1-1011-2021-4041-50