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Clark & Associates PLLC
1990 W. Camelback Rd.
Phoenix, AZ 85013
Phone: 866-682-1372

Source of Income:

Employment
Self-employment
Entitlement (SSI, VA, DES)
Other

Annual Gross Household Income

$0-27,000
$28,000-38,000
$39,000-47,000
$48,000-54,000
$55+

Marital Status: Married

Single
Married
Separated
Widow

Housing is:

Mortgaged
Rented
Owned outright

Auto:

Loan payments
Leased
Owned outright

Estimate Other Debt (other than house and car)

Total Number of Household Members

Prior bankruptcy filing

Ch 7
Ch 13

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