Unpaid Medical 1. Amount Owed (amount of claim): Is there a codebtor or No Bills cosigner on this loan? 2. Creditor Name and Address: Yes No Yes If yes, please provide name and address: 3. Account Number, if any: 4. of dates when debt was incurred: 5. Contact person's name and address if different: 6. Any additional information about the debt: Unpaid Medical 1. Amount Owed (amount of claim): Is there a codebtor or No Bills cosigner on this loan? 2. Creditor Name and Address: Yes No Yes please provide If yes, name and address: 3. Account Number, if any: 4. Date/range of dates when debt was incurred: 5. Contact person's name and address if different: 6. Any additional information about the debt:
Unpaid Medical Bills 1. Amount Owed (amount of claim): 2. Creditor Name and Address: 3. Account Number, if any: 4. of dates when debt was incurred: 5. Contact person's name and address if different: 6. Any additional information about the debt: Is there a codebtor or cosigner on this loan? No Yes If yes, please provide name and address: No Yes Unpaid Medical Bills 1. Amount Owed (amount of claim): 2. Creditor Name and Address: 3. Account Number, if any: 4. Date/range of dates when debt was incurred: 5. Contact person's name and address if different: 6. Any additional information about the debt: Is there a codebtor or cosigner on this loan? No Yes If yes, please provide name and address: No Yes
Consumer-Bankruptcy-questionnaire.docx