Mark any of the following statements that apply to you and, if you are married, include any that apply to your spouse.

General Information

   1.  __Yes __No I have filed bankruptcy before
                             When:_________________
                                __Chapter 7 __Chapter 13
   2.  __Yes __No I have lived outside of Iowa at some time during the last 2 years.
   3.  __Yes __No I have filed my income taxes every year.

Information About Your Debts

   4.  __Yes __No My total debt (NOT including mortgage or car loans) is:
                                                                                      __ Less than $10,000 
                                                                                      __$10,000-25,000 
                                                                                      __ $25,000-50,000 
                                                                                      __ Over $50,000
   5.  __Yes __No Most of my debt is credit card debt.
   6.  __Yes __No I have used credit cards in the last six months.
   7.  __Yes __No I have used my credit cards to cash advance in the last 60 days.
   8.  __Yes __No I have medical debt.
   9.  __Yes __No I have debt for bills from a previous marriage.
 10.  __Yes __No I have past due alimony or child support debts.
 11.  __Yes __No I have student loan debt.
 12.  __Yes __No I owe back income tax or other taxes.

Information About Your Home And Car

 13.  __Yes __No I am a homeowner.
 14.  __Yes __No When I bought my home I was debt free.
 15.  __Yes __No I have a second mortgage on my home.
 16.  __Yes __No I am behind by one or more payments on my mortgage.
 17.  __Yes __No I am behind by one or more car payments.

Information About Your Income

 18.  __Yes __No I have suffered a loss of income which is contributing to my debt problems.
 19.  __Yes __No I am living on social security or disability payments.
 20.  __Yes __No I am living on a pension.
 21.  __Yes __No I am self-employed.

Information About Your Expenses

 22.I pay the following average monthly bills: 
                      __rent/mortgage 
                      __gas/heat
                      __electric 
                      __water/sewer 
                      __cable
                      __telephone
                      __cell phone 
                      __internet
                      __food
                      __clothing
                      __laundry/dry cleaning 
                      __medical/dental
                      __gas for vehicle 
                      __normal vehicle repairs 
                      __house/renter?s insurance (if not included in house payment) 
                      __life insurance 
                      __health insurance (if not deducted from pay)
                      __auto insurance
                      __property tax (if not included in house payment) 
                      __auto payment on 1st car
                      __auto payment on 2nd car 
                      __installment payment on secured items
                      __student loan 
                      __back income tax
                      __fines 
                      __support/ alimony
                      __daycare 
                      __school activities 
                      __other 
                      __Total