Law Offices of Paul Moses

Creditor Information Sheet

Please list all your debts on this page. You can submit information for 5 creditors per form. Submit as many forms as needed. Please be sure to put your name on each form submitted so that we can identify who the information is coming from. If you file a bankruptcy, the law requires that you list all your creditors even if you intend to repay them. You can sign an agreement called a "reaffirmation agreement" with any creditor you wish to repay. Be sure to include debts which you believe might be non-dischargeable, such as student loans, or taxes.
Name:
Email:
Phone:
Please fill in all of the following information completely. We must have an account number (if there is one) and an address for each creditor.
Creditor Detail 1
Name:
Account number:
Account type:
Address:
City, State, Zip:
Amount of monthly payment:	$	Secured Unsecured
Amount owed:	$
Date debt incurred:
Last charge:	Date:
	Amount:	$
Last payment:	Date:
	Amount:	$
(If in collection, include collector name, address and account number below.)
Collector Detail 1
Name:
Address:
City, State, Zip:
Account Number:
Creditor Detail 2
Name:
Account number:
Account type:
Address:
City, State, Zip:
Amount of monthly payment:	$	Secured Unsecured
Amount owed:	$
Date debt incurred:
Last charge:	Date:
	Amount:	$
Last payment:	Date:
	Amount:	$
(If in collection, include collector name, address and account number below.)
Collector Detail 2
Name:
Address:
City, State, Zip:
Account Number:
Creditor Detail 3
Name:
Account number:
Account type:
Address:
City, State, Zip:
Amount of monthly payment:	$	Secured Unsecured
Amount owed:	$
Date debt incurred:
Last charge:	Date:
	Amount:	$
Last payment:	Date:
	Amount:	$
(If in collection, include collector name, address and account number below.)
Collector Detail 3
Name:
Address:
City, State, Zip:
Account Number:
Creditor Detail 4
Name:
Account number:
Account type:
Address:
City, State, Zip:
Amount of monthly payment:	$	Secured Unsecured
Amount owed:	$
Date debt incurred:
Last charge:	Date:
	Amount:	$
Last payment:	Date:
	Amount:	$
(If in collection, include collector name, address and account number below.)
Collector Detail 4
Name:
Address:
City, State, Zip:
Account Number:
Creditor Detail 5
Name:
Account number:
Account type:
Address:
City, State, Zip:
Amount of monthly payment:	$	Secured Unsecured
Amount owed:	$
Date debt incurred:
Last charge:	Date:
	Amount:	$
Last payment:	Date:
	Amount:	$
(If in collection, include collector name, address and account number below.)
Collector Detail 5
Name:
Address:
City, State, Zip:
Account Number:

[Basic Information] [Current Asset Information] [Current Monthly Expenses] [Creditor Information]

19100 Von Karman Avenue • Suite 400 • Irvine, CA 92612
Telephone: (949) 851-9120 • Facsimile: (949) 851-3834 • Email: pamoses@pamoseslaw.com