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F3 .... chapter 13 bill consolidation (where you had a payment program to repay your <br /> debt)? <br /> a. No <br /> b. Yes <br /> F4 .... been referred to a collection agency? <br /> a. No <br /> b. Yes • <br /> F5 .... repossession of property(voluntary or involuntary)? <br /> a. No <br /> b. Yes <br /> F6 .... had wages garnisheed (or attached)? <br /> a. No <br /> b. Yes <br /> F7. Do you currently have a government subsidized educational loan (school loan)that is <br /> delinquent(i.e., you are behind on the payments)? <br /> a. No <br /> b. Yes <br /> F8. Have you ever failed to file an income tax return? <br /> a. No <br /> b. Yes, 1 time <br /> c. Yes, 2 times <br /> d. Yes, 3 or more times <br /> F9. What is the largest amount you have ever gambled with on any one day?(INCLUDE ANY <br /> TYPE OF GAMBLING,SUCH AS IN A CASINO,A LOTTO WAGER,A CARD GAME,A HORSE RACE,OR A <br /> SPORTS BETTING POOL) <br /> a. I have never gambled <br /> b. $50 or less <br /> c. $51 to$100 <br /> d. $101 to$500 <br /> e. $501 to$1000 <br /> f. $1,001 to$10,000 <br /> F10. Have you ever owed money on a gambling debt? <br /> a. No <br /> b. Yes <br /> F11. Do you feel that you have ever had a problem with betting money or gambling? <br /> a. No <br /> b. Yes <br /> F12. Have people ever criticized your gambling? <br /> a. No • <br /> b. Yes <br /> F13. Has your gambling ever caused problems in your work or personal life? <br /> a. No <br /> b. Yes <br /> PSS/LEPS PLLC 72 <br />