Debt Negotiation > Free Debt Evaluation
Let us help you!  Complete the form below regarding your financial status and we will contact you after reviewing it.  All information you provide is strictly confidential and will be deleted within 30 days.*
 Personal Info
First Name:  
Last Name:  
Email:  
Address:  
Apt/Floor:  
City:     State:   Zip:
Telephone:  
Please specify day and time to be contacted: 
     
 Bills
What type of bills do you have?  Please check all that apply:
Credit Cards Tax Debts
Medical Bills Government Fines      (parking tickets, moving
     violations, suspensions)
Judgments
Student Loans Personal Loans
Total Number of Bills: 
Total Amount:  
Under $5,000
$10,000-$15,000
$15,000-$20,000
$20,000-$30,000
$40,000-$50,000
Over $50,000
Additional Info:
     
 Property
Home:
Approximate value of home: $
Approximate balance on mortgage: $
Monthly mortgage payment: $
Are you up to date on your mortgage payments?  Yes  No   
Are there any other mortgages on this property?  Yes  Yes   
     
Vehicles:
Vehicle 1:
Year:  Make:  
Model:  
Approximate value:   $
Approximate balance:   $
Monthly payment:   $
Are your payments  
up-to-date?   		Yes No   
 
Vehicle 2 (optional):
Year:  Make:  
Model:  
Approximate value:   $
Approximate balance:   $
Monthly payment:   $
Are your payments  
up-to-date?   		Yes No   
     
Other:
Please list any other significant property:
     
 Income
You:
How often do you get paid?
Every week
Every 2 weeks
Twice a month
Monthly
Net pay: $
(after taxes, medical & other deductions)
 
Spouse (optional):
How often do you get paid?
Every week
Every 2 weeks
Twice a month
Monthly
Net pay: $
(after taxes, medical & other deductions)
     
Other Income:
What other types of income do you have?  Please check all that apply:
Disability Part-time job
Social Security Child Support
Pension Unemployment
Rental Property Worker's Compensation

*If you decide to work with Joshua Spirn & Associates, the information submitted may be retained for a longer period of time.