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1. Personal Information First Name: Last Name: Email Address: Street Address: City: State: WA Zip: Phone:

2. Bills (check all that apply) Credit Cards Personal Loans Home Mortgage Judgments Tax Debts Government Fines (i.e., parking tickets) Student Loans Auto Loans Medical Bills     Credit Card balance:$ Home Mortgage balance: $ Student Loan balance:$ Tax Debt balance:$ Auto Loan balance:$

3.  Property Approximate Value of Home:$ Monthly Mortgage Payment:$ Are you behind on your mortgage payments? yes no Vehicles you own or make payments on? 1 2 3 4 5 Monthly Car Payments:$ Are you behind on your car payments? yes no

4. Income Monthly Household Income (after taxes and deductions): $ Other Monthly Income: Disability Part-Time Job (check all that apply) Social Security Child Support   Pension Unemployment   Rental Property Workers' Compensation

5. How Did You Hear About Law Offices of Timothy J. Wilson? Google AOL Search MSN Yahoo Ask Jeeves Craig's List City Search Yellow Pages BankruptcyAction.com Findlaw.com Attorney Referral Personal Referral Other Saw Building Other Search Engine: Other Website:

6.  Finish Select Date Time: 8:00 A.M. 9:00 A.M. 10:00 A.M. 11:00 A.M. 12 Noon 1:00 P.M. 2:00 P.M. 3:00 P.M. 4:00 P.M. 5:00 P.M. 6:00 P.M. 7:00 P.M. Please enter the phone number you would prefer to be contacted at: