Date
Have you made an appointment with our office yet?
If "Yes," for what day?
Month
January
February
March
April
May
June
July
August
September
October
November
December
Day
01
02
03
04
05
06
07
08
09
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
Year
2005
2006
2007
2008
2009
2010
Name -
Spouse's Name -
Mailing Address (Apt. #)
Mailing Address (If different) (Apt. #)
City, State, Zip
City, State, Zip
Employer, Position
Employer, Position
Home Phone
Home Phone
Work Phone (ext.)
Work Phone (ext.)
Cell Phone
Cell Phone
Email
Email
HOW_DID_YOU_HEAR_ABOUT_US
Please explain other
How long have you lived at your present address?
Marital Status
If divorced or separated, for how long?
Do You own any real estate?
Yes
No
What is the value? (best guess)
Do you own or operate a business?
Yes
No
If yes, what type?
Do you have any of the following property?
Savings Account - How much?
Stocks, Bonds, Investments - How much?
Retirement account - How much?
Have you ever filed Bankruptcy before?
Yes
No
If yes, when, what type, and where?
Are you suing anybody or is anybody suing you?
Yes
No
If yes, explain.
If no, could you sue anybody?
Do you or your spouse pay child support?
Yes
No
If yes, are you behind on payments, and if so by how
much?
If you are paying on a house or vehicle, are you behind
on these payments?
Yes
No
1st
House
Vehicle
# of Months?
2nd
House
Vehicle
# of Months?
3rd
House
Vehicle
# of months?
Do you have any student loans?
Yes
No
If yes, for what years? What type? Amounts?
Do you owe any Federal, State, Sales, or Property taxes?
Yes
No
If yes, for what years?
Are any of your debts co-signed with anyone other than
your spouse?
Yes
No
If yes, which ones and by whom?
Are you paying any debts back to family members?
Yes
No
If yes,to whom & how much paid in the last 12 months?
What is your approximate take home income per
month (not per pay period) after deductions for taxes,
social security, and insurance? (Please include
spouse's income whether filing a case with you or not)
You
Your Spouse
Job
2nd Job
Business
Food Stamps
Child Support
Retirement
Other Sources
Are there any special deductions out of your pay?
You
Retirement Plans
Yes
No
How Much?
Loans to Employer
Yes
No
How Much?
Allotments to Creditors
Yes
No
How Much?
Your Spouse
Retirement Plans
Yes
No
How Much?
Allotments to Creditors
Yes
No
How Much?
Loans to Employer
Yes
No
How Much?
What are your approximate expenses per month for
the following items?
Mortgage/Rent
2nd Mortgage
3rd Mortgage
Maintenance Fees
Medical
Electricity
Laundry
Water
Hair Cuts
Gas
1st Vehicle
Cable
2nd Vehicle
Telephone
3rd Vehicle
Gasoline
Furniture/Appliance Payment
Car Maintenance
Clothing
Car Insurance
Child Support
ANY
OTHER EXPENSES
Food
(Ex: Diapers, Child Care,
Mortgages and Other House Related Debts
Name of Creditor
Balance (Best Guess)
Value of Real Estate
1.
2.
3.
4.
Car Debts
Name of Creditor
Balance (Best Guess)
Type & Year of Car
1.
2.
3.
4.
Credit Cards
Name of Creditor
Balance (Best Guess)
1.
2.
3.
4.
5.
6.
7.
8.
Signature Loans with Collateral
Name of Creditor
Balance (Best Guess)
1.
2.
3.
Signature Loans without Collateral
Name of Creditor
Balance (Best Guess)
1.
2.
3.
Medical Bills
Name of Creditor
Balance (Best Guess)
1.
2.
Student Loans
Name of Creditor
Balance (Best Guess)
1.
2.
Loans to Family and Friends
Name of Creditor
Balance (Best Guess)
1.
2.
3.
Others
Name of Creditor
Balance (Best Guess)
1.
2.
3.
4.
Back Tax Debt
Name of Creditor
Type of Tax
Year
Balance
1.
IRS
State
Income
General Excise
Employment
2.
IRS
State
Income
General Excise
Employment
3.
IRS
State
Income
General Excise
Employment
4.
IRS
State
Income
General Excise
Employment
5.
IRS
State
Income
General Excise
Employment
6.
IRS
State
Income
General Excise
Employment
General Comments
Please click on the submit button to transmit the above
information about you to our office. This information
is necessary for a complete consultation regarding your
situation.
