All information MUST be filled out in its
entirety. You are required by law to answer all questions. If the
answer to the question is "none" write in "none" or
"0." You may fill the form out online and then print the
completed form or print a blank copy and fill in the answers yourself.
Mail the completed form with your signature at the bottom to:
Hoffman Law Office
713 Landis Ave.
Vineland, NJ 08360
Any falsification of information
contained herein is punishable by law.
| Name | |
| Street Address | |
| Address (cont.) | |
| City | State/Province |
| Zip/Postal Code |
Date of Birth -- mm/dd/yy Social Security #
Drivers License # and expiration date: (if no Driver's License, write "none")
Expiration date: --mm/dd/yy
Full Name and address of employer: (if not employed, write "none")
| Employer Name | |
| Street Address | |
| Address (cont.) | |
| City | State/Province |
| Zip/Postal Code |
Weekly salary (if none, write "none"):
Gross:
Net:
If not presently employed, name and address of last employer. If never employed, write "none"
| Employer Name | |
| Street Address | |
| Address (cont.) | |
| City | State/Province |
| Zip/Postal Code |
Is there currently a wage execution on your salary?
Yes
No
List the names, addresses, and account numbers of all bank accounts on which your name appears. If none, write "none."
Check any of the following sources of income from which you receive money:
Alimony
Loan Payments
Rental Income
Pensions
Bank Interest
Stock Dividends
None of the above
For any of the income sources you checked above, list the amount, how often, and the name and address of the source of income:
Do you receive Social Security benefits?
Yes
No
Do you own the property where you reside?
Yes
No
a. Name of the property owner or owners
b. Date property was purchased
-- mm/dd/yy
c. Purchase price
$
d.
Name and address of mortgage holder
Name:
Address:
City/State/Zip:
e. Balance due on mortgage
$
Do you own any other real estate?
Yes
No
a. Address of property
b.
Date property was purchased
-- mm/dd/yy
c.
Purchase price
$
d. Name and address of all owners:
e. Name and address of mortgage holder
Name:
Address:
City/State/Zip:
e.
Balance due on mortgage
$
f. Names and address of all tenants and monthly rental paid by each tenant:
If you answered "yes" to either questions 12 or
13, does the present value of your personal property, which includes
automobiles, furniture, appliances, stocks, bonds, and cash on hand, exceed
$1,000?
Yes
No
If "yes" you must itemize all property owned by you:
a. Cash on hand: $
b. Other personal property: (Set forth make, model, and
serial number. If financed, give name and address
of party to whom payments are made)
Do you own a motor vehicle?
Yes
No If Yes, state the following for each vehicle owned:
a. Make, model, and year of motor vehicle. If No vehicles owned, write
"none"
b. If there is a lien on the vehicle, state the name and address of the lien
holder and the amount due to the leinholder:
c. License plate #
d. Vehicle Identification #
Do you own a business?
Yes
No If yes, state the following:
a. Name and address of the business
b. Is the business a:
Corporation
Sole
Proprietorship
Partnership
c. The name and address of all stockholders, officers and/or partners:
d. The amount of income received by you from the business during the last
twelve months:
$
Set forth all other judgments that you are aware of that
have been entered against you and include:
a) Creditor's name
b) Creditor's attorney
c) Amount due
d) Name of Court
e) Docket #
I hereby certify that the foregoing statements made by me are true. I am aware that if any of the foregoing statements made by me are willfully false, I am subject to punishment.
Signature:________________________________________ Date: ___________
Mail this completed form to:
Hoffman Law Office
713 Landis Ave.
Vineland, NJ 08360