Client Bankruptcy Intake Form

Single Married Separated Divorced Widowed

Name and Address

First Name

Middle Name

Last Name

Suffix

Home

Cell

Date of Birth: (MM/DD/YYYY)

Email

Address

City

State

Zip

County

ITIN:

Have you lived at this address for at least 180 days?

Yes No

Have you ever filed a bankruptcy case before?

Yes No

Previous Case 1:

Case Name

Date Filed

Unsure

Case Number

Unknown

District if (known)

What is the total number of people living in your household including your spouse:

Time-sensitive legal situations

How you discovered us

Debtor's Income Information

Are you currently employed:

Yes No

Gross Inc./Month

$

Have you had any Self Employment Income:

Yes No

Avg. Monthly Inc.

$

Rent and other real property income:

Yes No

Avg. Monthly Inc.

$

Interest, dividends, and royalties:

Yes No

Avg. Monthly Inc.

$

Pension and retirement income (NOT Social Security) (Retirement Income):

Yes No

Avg. Monthly Inc.

$

Regular contributions from others to the household expenses, including child support:

Yes No

Avg. Monthly Inc.

$

Unemployment Compensation:

Yes No

Avg. Monthly Inc.

$

Social Security income. (SSI Income):

Yes No

Avg. Monthly Inc.

$

Other government assistance you receive regularly:

Yes No

Avg. Monthly Inc.

$

Other sources of income not already mentioned:

Yes No

Avg. Monthly Inc.

$

Co-Debtor's/Non-Filings Spouse's Income Information

Are you currently employed:

Yes No

Gross Income Per Month

$

Have you had any Self Employment Income:

Yes No

Avg. Monthly Inc.

$

Rent and other real property income:

Yes No

Avg. Monthly Inc.

$

Interest, dividends, and royalties:

Yes No

Avg. Monthly Inc.

$

Pension and retirement income (NOT Social Security) (Retirement Income):

Yes No

Avg. Monthly Inc.

$

Regular contributions from others to the household expenses, including child support:

Yes No

Avg. Monthly Inc.

$

Unemployment Compensation:

Yes No

Avg. Monthly Inc.

$

Social Security income. (SSI Income):

Yes No

Avg. Monthly Inc.

$

Other government assistance you receive regularly:

Yes No

Avg. Monthly Inc.

$

Other sources of income not already mentioned:

Yes No

Avg. Monthly Inc.

$

Rent or Own:

Rent Own

Monthly Rent

$

Property in foreclosure?

Yes No

Foreclosure sale date been set?

Yes No

Notes:

Foreclosure Date: MM/DD/YYYY

(LIST ALL VEHICLES YOU OWN, WHETHER YOU OWE MONEY ON THEM OR NOT)

Yes No

(Please list any & ALL types of property listed above you possess, own or use even if you're not on the title or registration.)

Example: A Secured Debt, is when you take out a loan on a specific item that can be taken back if you default on payments like a car, boat, or house. List all items that you have as secure debt(s).

Do you have any additional liens or loans secured against any real or personal property not already listed?

Yes No

Secured Loan 1:

Creditor Name

Street Address

City

State

Zip code

Property Description:

Monthly Payment Amount

$

Amount due

$

Date: (MM/YYYY)

Add More

Secured Loan 2:

Creditor Name

Street Address

City

State

Zip code

Property Description:

Monthly Payment Amount

$

Amount due

$

Date: (MM/YYYY)

Add More

Secured Loan 3:

Creditor Name

Street Address

City

State

Zip code

Property Description:

Monthly Payment Amount

$

Amount due

$

Date: (MM/YYYY)

Add More

Secured Loan 4:

Creditor Name

Street Address

City

State

Zip code

Property Description:

Monthly Payment Amount

$

Amount due

$

Date: (MM/YYYY)

Add More

Have you filed all of your Federal & State Tax Returns over the last 5 years

Yes No

Estimated Total Credit Card Debt

$

Estimated Total Medical Debt

$

Estimated Total Student Debt

$

Estimated Lawsuit / Judgement

$

Estimated Total Personal Loans

$

Estimated Total Credit Union Loans

$

Estimated Total Loans From Family

$

Estimated Other types of Debts

$

Have you made any major purchases or used credit cards for purchases over the last 3 months?

Yes No

Do you bank at or with any bank you have credit cards with also?

Yes No

What is the payoff for your vehicle?

Yes No

Are you being sued?

Yes No

Are your wages currently being garnished?

Yes No

Is there anything else you would like to share that would be useful for us to know for our appointment?

Client Bankruptcy Intake Form

Marital Status*

Debtor's Basic Information

Name and Address

Previous Case 1:

Co-Debtor's/Non-Filings Spouse's Information

Name and Address

Emergency Assessment

Time-sensitive legal situations

FIND

How you discovered us

Current Monthly Income

Debtor's Income Information

Co-Debtor's/Non-Filings Spouse's Income Information

Mortgages:

Vehicles/ Motorcycles/ Boats etc.:

Vehicle Type

Recreational Vehicle Type

Other Secured Loans:

Secured Loan 1:

Secured Loan 2:

Secured Loan 3:

Secured Loan 4:

Back taxes owed

IRS

State Back Taxes

Other Debts