Bankruptcy Intake Form

Bankruptcy Intake Questionnaire

Law Offices of Rod Miller, PC - (423) 650-7066
Full Name*

First NameLast Name
Social Security Number #
Birth Date

MonthDayYear
Home Physical Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry
Mailing Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
County*
Mobile Phone Number*

Area CodePhone Number
Home Phone Number

Area CodePhone Number
E-mail*
Work Phone

Area CodePhone Number
Current Employer?
Martial Status

SingleMarriedSeperatedDivorcedWidowed
Spouse's Information
Spouse's Full Name

First NameLast Name
Spouse's Social Security #
Birth Date

MonthDayYear
Spouse's Home Physical Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry
Spouse's Mailing Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Spouse's Mobile Phone Number

Area CodePhone Number
Spouse's Home Phone Number

Area CodePhone Number
Spouse's E-mail
example@example.com
Spouse's Work Phone

Area CodePhone Number
Spouse's Current Employer?
Alternate Contact(s) Where You Can Be Reached

In the event the numbers and email address above do not work:
Alternate Contact Name

First NameLast Name
Relationship
Phone Number

Area CodePhone Number
Email
example@example.com
Please Answer Each of the Below

Your explanations assist us with the process.
Have you or your spouse filed any bankruptcies during the last eight (8) years?

Yes (Explain Below)No
Where Filed
Type of Filing

Chapter 7Chapter 13
Case Number
Date Filed

MonthDayYear
Date
Is your spouse or business partner in a bankruptcy case?

YesNo
Name of Debtor
Relationship
Case Number
Date Filed

MonthDayYear
Date
Do you or your spouse owe any back taxes?

YesNo
If yes, explain what type and how much:
Has any person or entity taken a judgment against you?

YesNo
If yes, provide explanation:
Do you or your spouse owe any student loans?

YesNo
If yes, provide explanation:
How did you find us?*

Internet-WebsiteFacebookYellowbookNewspaper AdRefferalOther
Any Other Notes:
Should be Empty:

Bankruptcy Intake Questionnaire

Spouse's Information

Alternate Contact(s) Where You Can Be Reached

Please Answer Each of the Below