First Name: Last Name:

Street Address:

City: State: Zip Code:

E-mail Address:

Daytime Telephone Number:

Evening Telephone Number:

Cell Phone Number:

How do you prefer we contact you?

Telephone   E-mail

If by telephone, when is the best time to call you?

What was the date your bankruptcy petition was filed?

What kind of bankruptcy did you file?

Chapter 7 Chapter 13

Did you obtain a discharge? Yes No

If so, on what date?

Do you have a copy of your Discharge Order? Yes No

Have you obtained a copy of your credit report in the last 12 months? Yes No

If so, from what credit bureau(s)?

Have you attempted to obtain credit since receiving your discharge? Yes No

Have you received any letters or telephone calls seeking to collect debts that were discharged in your bankruptcy? Yes No