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Working Together

Debt Relief Assessment Form

Client Use Only– Debt Expert Inc.

Client Information

Date of Birth
Year
Month
Day
Lives on Reservation
Yes
No
Marital Status
Currently in Bankruptcy or Proposal?
Yes
No
Previously Filed Bankruptcy/Proposal?
Yes
No
Most Recent Tax Return Filed
Yes
No
Other

Income & Employment

Income Source(s)

Debt Summary

( include all unsecured debts with name of creditor and amount owing example: credit cards, payday loans, personal loans, lines of credit, student loans, old bills/collections debt & government debt)

Asset Disclosure

Asset Type : Vehicle

Vehicle #2 (if needed)

Asset Type : Real Estate

Asset Type : Bank Accounts

Asset Type: Life Insurance

Asset Type: Other

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