Please complete each question that pertains to your situation.
1. Are you currently employed?
2. Marital status?
3. What is your age?
4. What is the value of your 401(k)?
$1 to $5,000
$5,001 to $10,000
$10,001 to $20,000
5. What is the current value of your home?
6. What is your current home loan balance?
(Include all money owed where your home is the lender's security.)
7. Number of mortgage payments delinquent:
8. Are you currently looking for a home loan?
9. What is the value of your automobile(s)?
10. What is the balance on your auto loan(s)?
11. How much do you owe in student loan(s)?
12. How much do you owe the IRS in delinquent taxes?
13. Do you have any judgments?
14. Is a Pension, Social Security, Disability, Veteran's Benefits, Worker's Compensation, Public Assistance, Child Support or Alimony your main source of income?