Exit Form Exit Form 1). Have you ever owned a house, co-op condo, land or time share, whether in your name for your benefit or for the benefit of another person in this country or outside this country?* Yes No Untitled2). Do you have a personal injury lawsuit, disability claim, or worker's comp case or auto insurance claim pending?* Yes No Untitled3). Do you currently have any other type of lawsuit, legal claim or insurance claim? If yes, has there been talk of a recent settlement, or will there be an upcoming trial on this? If you do have a lawsuit or claim, provide status of your case.* Yes No Untitled4). Has anyone died or is likely to die within the next 6 months that entitled you to an inheritance? The deceased may have died with a will or without a will.* Yes No Untitled5). Are you expecting life insurance proceeds as a result of an actual death that has occurred?* Yes No Untitled6). Are you involved in a divorce where there will be a property settlement or a change in marital status?* Yes No Untitled7). What do you project your tax refund to be for next year?8). Have you made any purchases, cash advances, or incurred any other debt since first coming into our office?* Yes No Untitled9). Have you made any transfers to friends or family members or payments to creditors since first coming into our office?* Yes No Untitled10). Have you previously filed bankruptcy & when?* Yes No Untitled11). Did you anticipate an increase in your salary or any other change in your financial circumstance during the next 12 months?* Yes No Untitled12). Do you have or have you had any involvement or ownership interest formally or informally in any business in this country or outside of this country?* Yes No Untitled13). Do you or did you change or expect to change your marital status? Marriage, divorce or separation?* Yes No UntitledIf you are a homeowner, any post-bankruptcy loan modification will affect your bankruptcy discharge status. Thus, do not sign any loan modification agreement without consulting our office.I HAVE READ THIS FINAL QUESTIONNAIRE AND MY ANSWERS ABOVE ARE TRUE AND ACCURATE TO THE BEST OF MY KNOWLEDGE AND BELIEF.Signature First Last
