Bankruptcy Intake Form and Service Questionnaire

*Name

*Address

*City

*State

*Zip:

*E-mail address:

*Home Phone:

Business Phone:

Cellular or Pager:

Facsimile:

Do you intend to file a joint bankruptcy petition?

YesNo

If yes, include information for both yourself and your spouse below.

Name(s), including middle initial.

*Residence address, including county.

How long have you been at this address?

Other Address How Long?

Other telephone number(s)

Work:

Cell:

Other:

Have you used any other name(s) in the last six years?

YesNo

If yes, please list here

SingleSeparatedMarriedDivorced

If married, how long?

If divorced, how long?

Ages of minor children living with you

Ages, and amount of child support paid:

Age Amount
$
$
$
$

Is any child support past due?

YesNo

Amount

$

Husband's employment:

How long at this job?

Occupation

Income paid

Gross

Net

Wife's employment (name and addr.):

How long at this job?

Occupation

Income paid
weeklysemi-monthlymonthlyother

Gross

Net

Income from other sources (second job, investments, social security, child support, worker's compensation, etc. (state source and amount):

Do you owe any money to the Internal Revenue Service?
YesNo

If yes, for what year(s)?

How much?

Do you have any unpaid student loans?
YesNo

Amount
$

Monthly Expenses

Rent Real Estate Taxes

Electric Home Maintenance

Gas Life Insurance

Water Health Insurance

Phone Auto Insurance

Cable Homeowner/Rent Ins.

Trash House Payment

Do you pay anyone spousal support (alimony)
YesNo

If yes, to whom and how much?

Do you own or are you purchasing a home or other real property?
YesNo

Tax assessed value
$

First Mortgage Loan Balance
$

Loan Current?

Amount Behind
$

2nd Mortgage Loan Balance
$

Loan Current?

Amount Behind
$

3rd Mortgage Loan Balance
$

Loan Current?

Amount Behind
$

Are you facing foreclosure?
YesNo

Foreclosure Date

List any liens against your property

List all vehicle loans (car, truck, motorcycles; identify vehicle type)

Vehicle
Est. Loan Balance $
Loan Current
Amount Behind $
Vehicle
Est. Loan Balance $
Loan Current
Amount Behind $
Vehicle
Est. Loan Balance $
Loan Current
Amount Behind $

List all vehicles you own outright (no loan balance)

Vehicle Est. Value
$
$

Have you purchased any secured items (electronics, boats, jet ski, appliances, etc.) in the last two years on which you still owe money?
YesNo

Have you taken out a loan from a finance company, credit union, bank or any other place and secured the loan by household items or other type of secured collateral?
YesNo

Creditors' Names

Estimate balances owed on all other types of debt listed below

$ Medical Bills

$ NSF Checks

$ Credit Cards

$ Misc. Bills

When was the last time you used any of your credit cards? (approx. date)

How much has total owed on cards gone up in the last 12 months?

Have you had any new cards issued in the last 12 months?

Do you anticipate receiving a tax refund?
YesNo

How much?

Are you eligible for the Earned Income Credit?
YesNo

How much?

List all judgments, lawsuits, liens and garnishments against you.

Special concerns

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