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Contact Information:
  Long Island Bankruptcy - New York Bankruptcy
Law Office of Ronald D. Weiss, P.C.
734 Walt Whitman Rd. Suite 203
Melville, NY 11747
  Phone: (631) 271-3737
Mobile: (631) 650-8760
Fax: (631) 271-3784
Website: www.longislandbankruptcy.com
Email: weiss@ny-bankruptcy.com
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NOTE: Free consultation for individuals and businesses throughout Long Island and the Greater New York City area only.

This free consultation is limited to residents of the Greater Long Island - New York City area. Please provide us with as much information as possible by submitting the form below. If you prefer, you can print this form, then fill it out, and fax it to us at (631) 271-3784. Or, you may mail it to our office address listed above.

* Denotes Required Field

Name *
Address *
Address
City, State, Zip *      
Country
Home Phone *
Alternate Phone
Fax
E-mail *

Nature of financial difficulty

Services Sought
Type of Legal Services Sought Bankruptcy Case
Creditor Negotiation
Creditor Litigation
Other   Specify:
Not Sure

Please give approximate amounts, number of debts, creditors, and status (current or number of months arrears) for each category.
Type of Debt
Amount
Creditors
Status
Credit Card
Personal
Loans/Credit Lines
Medical Bills
Car Loans/Lease
Car Loans/Lease # 2
Mortgage
Mortgage # 2
Taxes
Business Related
Other (Specify)

Assets - Please give description and approximate fair market value of each.
Type of Asset
Description
Market Value
Ownership
House
Any Other Real Property
Car
Cash
Bank Account
Business
Pending Lawsuits
Investments
Retirement Account
Other Property Having Value

Income Versus Expenses
Average Monthly Net Income
Average Monthly Expenses

More Information Regarding Type of Debt
Credit Cards (If Applicable)  
Who is Liable?
Last Time Used?
Able to Pay at Time of use?
Any Cash Advances? If yes, when?
Any Luxury Items? If yes, when?
Rate of Use in the last year (Steady, High, Low)
Mortgage Arrears (If Applicable)  
Situation
Number of Months In Arrears
Amount of Mortgage Arrears
Monthly Mortgage Payment
Are you presently able to afford paying the regular monthly mortgage payment on a going forward basis? Yes:   No:
Are the Following Being Escrowed By Bank?
Taxes   Amount:
Insurance   Amount:
Amount currently able to pay (without taking into account the arrears)
Goal:  
Cause for Arrears
Who is liable on the mortgage
Who Owns the Home/Real Property
Who is living there
How did you hear about us?  
Yellow Pages, Specify
Internet Search, Specify
Other, Specify
Current Client, Specify
Other Referral, Specify
Letter
 
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