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How Can We Help You? Would you like to know more about how the Law Office of Blake Goodman can help you with your financial problems? Please take a moment to fill out the information on this page and click "submit" at the bottom. We will reply as soon as possible. If there is not enough space to complete your responses, then please put carry over information in the "General Comments" section at the end of this questionnaire.
Date: Have you made an appointment with our office yet? YESNO If "Yes," for what day?
First Name: MI: Last Name:
Mailing Address (Apt. #): City, State, Zip: Home Phone: Work Phone (ext.): Cell Phone: Email:
Employer, Position: Spouse's Employer, Position:
How Did You Hear About Us? NewspaperPhonebookTVRadioRecommendationInternet SearchOther How long have you lived at your present address? Marital Status:Married Single Divorced Separated If divorced or separated, for how long? Do you have any children under the roof with you or are otherwise dependents? YESNO If Yes, how many? What are their ages? Do You own any real estate? YESNO What is its value (best guess), if you have more than one piece, then please list in General Comments at the bottom: Do you own any burial plots/plans or timeshares? YESNO What is its value (best guess), if you have more than one piece, then please list in General Comments at the bottom: Do you have any vehicles? YESNO If Yes, how many, what make, what year and what approximate values? (best guess)
Do you own or operate a business? YESNO If yes, what type? Do you have any of the following property? Savings Account Stocks, Bonds, Investments Retirement account Have you ever filed Bankruptcy before? YESNO If yes, when, what type, and where? Are you suing anybody or is anybody suing you? YESNO If yes, explain. If no, could you sue anybody? YESNO
Do you or your spouse pay child support? YESNO 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? YESNO 1st HouseVehicle # of Months? 2ndHouseVehicle # of Months? 3rdHouseVehicle # of months? Do you have any student loans? YESNO Amounts? Do you owe any Federal, State, Sales, or Property taxes? YESNO If yes, for what years? Are any of your debts co-signed with anyone other than your spouse? YESNO If yes, which ones and by whom? Are you paying any debts back to family members? YESNO 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)
Are there any special deductions out of your pay?
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: Cable: Telephone: Gasoline: (All Vehicles): Furniture/Appliance Payment: Car Maintenance: Clothing: Car Payments: Car Insurance: Child Support: Food: Childcare:
ANY OTHER EXPENSES (Ex: Diapers, Dog Food, Cigarettes):
Please place overflow information here.
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.
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