D. Parker Law Online Bankruptcy Intake
Preferred name, if different
Your Phone Number
Phone is a:
Your Email Address
Street Address Line 2
State / Province
Postal / Zip Code
Antigua and Barbuda
Bosnia and Herzegovina
Central African Republic
Cocos (Keeling) Islands
Democratic Republic of the Congo
Turkish Republic of Northern Cyprus
Papua New Guinea
Republic of the Congo
Saint Kitts and Nevis
Saint Pierre and Miquelon
Saint Vincent and the Grenadines
Sao Tome and Principe
Trinidad and Tobago
Tristan da Cunha
Turks and Caicos Islands
United Arab Emirates
British Virgin Islands
Isle of Man
US Virgin Islands
Wallis and Futuna
Your Spouse's Name, if married
Spouse preferred name, if different
Your Spouse's Phone number
Phone is a:
Your Spouse's Email
Will your spouse be filling bankruptcy with you?
I’m not married
How long have you (and your spouse) lived in Idaho (or Malhuer County Oregon)?
How soon would like like to file your bankruptcy?
As soon as possible
I feel like it might be several months until I'm ready
I'm not sure
If you have filed bankruptcy before, what month and year?
How many people live in your household that you support (including yourself, spouse, children, stepchildren, dependent adults)
If you work, what is your approximate GROSS monthly income (before taxes, social security, etc.)
If your spouse works, what is their approximate GROSS monthly income (before taxes, social security, etc.)
If you or your spouse do not current work, but have worked within the last six months, what was you/their approximate GROSS monthly income (before taxes, social security, etc.) and what months did you/they work?
Is the gross amount of any paycheck from wages/salary that you or your spouse receive more than $2500 per paycheck?
Is any part of the compensation that you and/or your spouse receive commission-based?
If you or your spouse get income from any other source (child support, alimony, unemployment, social security, disability, etc.), how much do you receive a month?
Please list the sources of your income and your spouse's income in the last three years (wages/salary, investment income, child support, social security, unemployment, insurance settlements, lawsuit settlements, gifts, business income, royalties, gambling/lottery, 401k loans, bonuses, commissions, inheritances, etc.)
Do you own your own business or have an ownership interest in a business?
Not anymore but I have in the past
Have you been divorced within the last 10 years?
List the property that you were awarded in the divorce
List property that your ex-spouse was awarded in the divorce
Were you assigned debts to pay in the divorce?
Yes, but they have been paid
Yes, and they have not been paid
What was you ex-spouse's name?
Are you contemplating or currently involved with a divorce?
Have you been sued by any of your creditors?
Not yet sued but threatened with lawsuit
If you have been sued, has judgment been entered against you?
Yes, there is a judgment
No, the lawsuit is still pending
I'm not sure
Are you being garnished or levied? (check all that apply)
Notified of pending garnishment
Garnishment has occurred in the last year but is currently stopped
Creditors have threatened garnishment
Tax refund was taken
Bank accounts have been levied
Garnished by Child Support
Bank offset account to pay a debt you owed the bank
If you have been garnished or levied in the last year, who was/is garnishing you and how much did they take?
Are you involved with, contemplating, or have any right to bring a lawsuit against anyone yourself?
In the last four years, have you been in an auto accident, been injured in any sort of other accident, been injured at work, etc.? If so briefly describe those circumstances and any compensation you have received
Do you have any of the following retirement accounts (check all that apply)
401k or similar retirement account
Have you contributed money to any retirement accounts within the last 10 years, other than amounts withheld from your wages?
What is your living situation?
If you rent, what is the amount of your security deposit, if any?
What is your monthly payment on your mortgage/rent?
Are you behind at all on your mortgage/rent?
Have foreclosure or eviction proceedings been started against you?
If you have a mortgage, what is the current market value of your property according to Zillow.com?
If you have a mortgage, what is the current balance on your mortgage (total, both first and second/equity line)
Other than a mortgage, are you aware of any of liens against you personal or your property? (Judgment liens, mechanic's liens, medical indigent fund liens, HOA liens, tax liens, etc.
Other than your home, do you own any other real property? (Rentals, cabins, bare ground, timeshares, you have been added to the deed of someone else's property, etc.)
In the last four years, have you done any of the following with respect to your real property (check all that apply):
Purchased real property
Sold real property
Added someone else's name to the title of your real property
Modified a mortgage
Taken out an equity line of credit or HELOC
Used real property as collateral in any other way
Given any person or business a security interest in any of your property
Had real property foreclosed
How many vehicles do you own? (Cars, trucks, boats, motorcycles, ATVs, UTVs, motorhomes, snowmobiles, trailers, utility trailers, travel trailers, etc.)
Please list the type, year, Bluebook private sale value, and current loan balance (if any) with respect to each of these vehicles
Are you behind on any payments on any vehicle you own?
In order to protect an on-street vehicle (such as a car, truck, street motorcycle, or motorhome) in bankruptcy it must be registered, insured, street legal, current on any required emissions testing, and currently operational. Do all of your on-street vehicles qualify?
Would you like to get rid of any of the vehicles you current own in your bankruptcy? If so, list the vehicles that you want to surrender.
Is there any possibility that you have been added to the title of ANY ELSE'S property (added to the title of someone else's car, home, trailer, etc.) If so, please describe.
In the last year, have you done any of the following with respect to your vehicle(s)? (check all that apply)
Purchased a vehicle on credit
Purchased a vehicle outright
Refinanced a vehicle
Put a title loan on a vehicle
Added someone's else's name to the title of a vehicle you own
Used a vehicle as collateral in any other way
Granted any person or business a security interest in your vehicle
Totaled a vehicle
In the last two years, have you disposed of any of your titled vehicles in the following ways: (check all that apply)
Sold a vehicle
Given away a vehicle
Donated a vehicle
Scrapped a vehicle or signed it over to an insurance company
Other than real property or vehicles, do you have any other secured property (that is, property that could be repossessed if you stopped making payments)? Examples often include furniture, heat pumps, Kirby vacuums, etc.
If yes, please list what that property is, how much is owed, and its approximate value
Would you like to keep this secured property?
Do you currently have any items in pawn?
If you have a Health Savings Account or similar account, what is its current balance?
Are you the beneficiary of any trust?
Do you think you might receive an inheritance within the next year?
There is one in progress now
I think it is likely
Do you have any property, other than vehicles and real property, worth more than $500? Examples might include jewelry, paintings, antiques, guns, collectibles, electronics, tools, animals, season tickets, patents, copyrights, trademarks, memberships, water rights, crops, business interests, etc. If yes, please describe and provide the approximate value
Do you own firearms? What type and what is its value?
Do you own jewelry? What type and what is is value?
Have you done any of the follow with respect to your personal property within the last two years? (check all that apply)
Sold any of your personal property (garage sales, ebay, Craigslist, etc.)
Given away or gifted your personal property
Donated personal property to a charity or thrift store
Lost personal property to fire, flood, theft, etc.
Do you own stocks, bonds, bitcoin or similar accounts, or other investments outside of a retirement account?
Are you current on filing all your tax returns?
I haven’t had a filing requirement for at least 10 years
Are you expecting that you may receive a tax refund within the next six months?
If you are expecting a tax refund, how much are you expecting to get?
What was the amount of the last tax refund you received?
How did you spend your last tax refund?
Have you received your COVID 19 stimulus check?
Do you think you will receive any payments of more than $500 in the next six months, outside your usual income (back pay, bonuses, inheritance, insurance payments, lawsuit money, debts owed to you, etc.)? If so, list the type of payment and approximate amount.
Are you expecting a commission? If so, how much and what from?
Are you expecting student loan disbursements made to you in the next six months?
Have you done any of the following with your money within the last two years (check all that apply)
Given gifts of money (beyond small birthday/holiday-type amounts)
Donated money to charitable or religious organizations
Had money stolen from you
Loaned money to a business you are involved with, family, or friends
Does anyone owe you any money?
List all the places where you bank and the approximate current balance
Approximately how much cash do you have on hand?
What are the sources of deposits into your bank account (job, social security, retirement, etc.)?
Do you owe any money to your bank (personal lines of credit, overdrafts, credit cards, car loans, etc.)?
Are any of the following additional people are on your bank account? (check all that apply)
Are you on anyone else's bank account (on parent's account, child's, unmarried partner, etc.)
In the last four years, have you lived with an unmarried partner?
In the last four years, have you paid to have property that you do not own repaired, replaced, or improved?
In the last four years have you paid educational expenses for an adult other than your spouse or yourself?
In the last four years, have you made payments on property not titled in your name (for example, payments on houses, cars, or other property owed by your unmarried partner, child, family member, friend, etc.)
In the last four years, have you paid anyone else's debt, bills, or expenses for them (other than those of spouse/minor children). This includes paying the debts, bills or regular expenses of unmarried partners, adult children, family, friends, or others
Have you borrowed money from family or friends in the last two years?
If you have borrowed money from family or friends, how much have you borrowed?
If you have borrowed money from family or friends, how much have you repaid?
Other than payments on your house and car, have you paid any one creditor a total of more than $600 in the last 90 days (i.e., payments of $200 a month or more for the last three months)? List the creditor(s) and how much paid.
In the last year, have you worked with any debt relief/debt consolidation service?
What types of debt do you have? (check all that apply)
Secured debt (houses, cars, etc.)
Unsecured consumer debt (credit cards, personal loans, payday loans, medical bills, etc.)
Child support or alimony (monthly payments but not in arrears)
Child support or alimony (in arrears)
Criminal fines, fees, or restitution
Debts where it has been or might be alleged that you were engaged in fraud (embezzlement, unemployment fraud, etc.)
Debts where it has been or might be alleged that you were engaged in intentional injury to property or people
Debts you were ordered to pay in a divorce
Debts related to a DUI or injuring someone while driving under the influence
Debts to a utility company
Please check any of the following that apply regarding cosigned debts:
I am a cosigner on someone else's debt
Someone else is a cosigner on my debt
I have been making payments on a debt that someone else cosigned on for me
I have been making payments on a debt that I cosigned for someone else
What is your approximate amount of secured debt (houses, cars, etc.)
What is your approximate amount of unsecured debt (medical bills, credit cards, student loans, etc.)
Have you used any credit in the last six months? (credit cards, personal loans, payday loans, title loans, refinances, purchases on credit, purchase of a car or home, etc.)
Have you made any credit card balance transfers in the last six months?
What is happening in your life that has you contemplating bankruptcy at this time?
Were you confused about any of the questions asked of you, or need to provide any additional information you think we should know?
Have you already called D. Parker Law and scheduled your free consultation?
Should be Empty:
Now create your own JotForm - It's free!
Create your own JotForm