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 filed Bankruptcy in the past 8 years?

Yes No

If yes what chapter and date filed?

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

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

$

Do you have a loan on this property?

Yes No

You can find out the value of your home here zillow.com and/or redfin.com

Mortgage 1

Est. Mortgage - 1st Amount Owed

$

Monthly Payment - 1st

$

Est. Past Due Payments - 1st

$

If your current on this mortgage type in $0.00

Value of Property

$

Creditor Name

Street Address

City

State

Zip code

Do you have additional loans?

Yes No

Mortgage 2

Est. Mortgage - 2nd Amount Owed

$

Monthly Payment - 2nd

$

Est. Past Due Payments - 2nd

$

If your current on this mortgage type in $0.00

Creditor Name

Street Address

City

State

Zip code

Do you have additional loans?

Yes No

Mortgage 3

Est. Mortgage - 3rd Amount Owed

$

Monthly Payment - 3rd

$

Est. Past Due Payments - 3rd

$

If your current on this mortgage type in $0.00

Creditor Name

Street Address

City

State

Zip code

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.)

Please list all cars, trucks, motorcycles, boats or aircraft where your name is on the registration.

Click to get value here kbb.com and/or nada.com

Vehicle 1

(Examples: Boats, trailers, motors, personal watercraft, fishing vessels, snowmobiles, motorcycle accessories)

Estimated Value of Property

$

Year

Make

Model

Mileage

Style of Vehicle

Do you have a loan on this property?

Yes No

Monthly payment amount

$

Past due payment

$

Estimated Amount Owed

$

Creditor Name

Street Address

City

State

Zip code

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

IRS

Do you owe any back taxes to the IRS?

Yes No

Input which year(s)

Estimated Amount Due

$

State Back Taxes

Do you owe any back taxes owed to the State?

Yes No

State

Input which year(s)

Estimated Amount Due

$

Do you owe Child Support/Alimony?

Yes No

Select state:

Your Monthly Payment Amount

$

Are you current on your support obiligation(s)?

Yes No

Your Past Due Amount

$

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

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

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

Name and Address

Current Monthly Income

Debtor's Income Information

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

Mortgages:

Vehicles/ Motorcycles/ Boats etc.:

Other Secured Loans:

Secured Loan 1:

Secured Loan 2:

Secured Loan 3:

Secured Loan 4:

Back taxes owed

IRS

State Back Taxes

Other Debts