Are your wages currently being attached or garnished?
-Yes
-No
If yes, is the wage attachment for child support?
How old is the child(ren)?
If you are not employed, please indicate if you receive child support, unemployment compensation, disability income insurance, alimony, SSI or other compensation?
Do you receive any other forms of financial assistance? (Examples: food stamps, Section 8 housing, Medicare, help from family)
Are you able to work?
-Yes
-No
Are you in the military?
-Yes
-No
Is your spouse in the military?
-Yes
-No
Are you a veteran?
-Yes
-No
Disabled veteran?
-Yes
-No
Rent payment per month
$
Are you paying your rent on time?
-Yes
-No
-N/A
Mortgage payment per month
$
Are you paying your mortgage on time?
-Yes
-No
-N/A
Car payment per month
$
Are you paying your car payment on time?
-Yes
-No
-N/A
If you need more room to complete an answer, or would like to add additional information about your financial situation, please enter below.
This communication is an attempt to collect a debt and any information obtained
will be used for that purpose. This information is not intended to be legal
advice. If you have questions, please consult an attorney.