Bankruptcy Intake Form

The Law Office of Jonathan Augusta
Date*

MonthDayYear
How did you find us?*

ReferralSearch EngineADOther
Full Name*

First NameMiddle NameLast NameSuffix
Social Security Number #
Birth Date

MonthDayYear
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry
Phone Number*

Area CodePhone Number
Cell/Work

Area CodePhone Number
E-mail*
Name of Emergency Contact
Phone number
Have you filed Bankruptcy in the past 8 years?

YesNo
What chapter?
How many dependents/Children do you have?
Martial Status

SingleMarriedSeperatedDivorcedWidowed
- Spouse's Full Name
  
  First NameMiddle NameLast Name
- Spouse's Social Security #
- Birth Date
  
  MonthDayYear
- Gender
  
  MaleFemale
- Spouse's Address
  
  Street Address
  
  Street Address Line 2
  
  CityState / Province
  
  Postal / Zip CodeCountry
- Spouse's Phone Number
  
  Area CodePhone Number
- Has your spouse filed Bankruptcy in the past 8 years?
  
  YesNo
- What chapter?
- Total Number of People Living in Your Household
- Income:
  
  IF YOU ARE EMPLOYED THIS SECTION IS REQUIRED.
- Name and Address for your Current Employer
- Years?
- How often paid?
  
  WeeklySemi-2 weeksMonthly
- Average Take home paycheck
- Your average Gross Paycheck per payday
- Name and Address for your Spouse's Employer
- Years?
- Spouse's Average Take home paycheck
- Spouse's average Gross Paycheck per payday
- How often paid?
  
  WeeklySemi-2 weeksMonthly
- Retirement / Pension / Social Security per mo
- Spouse's Retirement / Pension / Social Security per mo
- Self Employed/ Business Net profit per mo
- Other Income
- Do you have any Minor dependents/children/kids?
  
  YesNo
- If so, how many do you have? Please list the age and gender of each dependent:
- Do you/they receive or are you court ordered to receive child support?
  
  YesNo
- Do you have a child support obligation?
  
  YesNo
- Type a question
- If so, how much child support are you obligated to pay? $blanks per
- Assets & Accounts:
- Do you have a Checking Account
- Do you have a Savings Account
- Do you have a (and/or your spouse if filing joint) have a 401K Account
- Mortgages:
  
  Please list your home and any other house, bare land or time share where your name is on the deed.
- Name and Address of Lender
- Eppraisal Zillow
- Payment/Mo - 1st
- Delinquent - 1st
- Principal Balance on House
- Value of the real property
- Name and Address of Second Lender
- Payment/Mo -2nd
- Delinquent - 2nd
- Principal Balance
- Property in foreclosure?
  
  YesNo
- Foreclosure sale date been set?
  
  YesNo
- Date of Sale
  
  MonthDayYear
- Do you have to pay a Home Owners Association?
  
  YesNo
- Monthly Amount of HOA
- Address of Home Owners Association
  
  Street Address
  
  Street Address Line 2
  
  CityState / Province
  
  Postal / Zip Code
- Are you Renting?
- Are you Renting a House or Apartment?
- Name of Landlord: blanks
  Address:   Street Address   Address Line 2   City   State   Zip
  Telephone:   Area Code   Phone Number
  Regular Monthly Payment:
  Arrears:
- Other Real Property
- Payment/Mo - 1st
- Delinquent - 1st
- Total Debt - 1
- Property in foreclosure?
  
  YesNo
- Foreclosure sale date been set?
  
  YesNo
- Payment/Mo -2nd
- Total Debt - 2
- Delinquent - 2nd
- Is your name on the deed of any other house, bare land, time share or burial plot?
  
  YesNo
- Leave Blank Notes for Attorney:
- Vehicles
  
  Please list all cars, trucks, motorcycles, boats or aircraft where your name is on the registration.
- Name of Car Lender
- 1st Estimated Value
- Kelly Blue Book
- 1st Vehicle Model Year
- Auto Maker
- Model
- Payment/Mo
- Delinquent
- Total Debt
- Mileage
- Name of Second Car Lender
- 2nd Vehicle Model Year
- Payment/Mo
- Model
- Payment/Mo
- Total Debt
- Auto Maker
- Mileage
- Kelly Blue Book
- Name of Third Car Lender
- 3rd Estimated Value
- 3rd Vehicle Model Year
- Auto Maker
- Model
- Payment/Mo
- Delinquent
- Total Debt
- Mileage
- Is your name on the registration of any other car, truck, motorcycle, boat or aircraft?
  
  YesNo
- Please list the make, model, year, and mileage of your other vehicles:
- TAXES AND OTHER PRIORITY DEBTS
- Internal Revenue - Year(s)
- Total IRS Taxes Due
- Franchise Tax Board - Year(s)
- Total State Taxes Due
- Child Support - Total Due
- Alimony - Total Due
- Who do pay you child support to :
- OTHER DEBTS
  
  Please give us your best estimate of other debts that you owe.
- Number of Credit Cards:
- Total Credit Debt:
- Have you made purchases in the last 3 months?
  
  YesNo
- Have you used one card to pay another?
  
  YesNo
- Do you have a checking account at a bank that issued the card?
  
  YesNo
- Total Medical debt
- Total Student loans:
- Law Suit/Judgement
- Total Personal Loans:
- Total Credit Union Loans:
- Total loans from family:
- Income Taxes (not deducted from paycheck):
- Past Due Taxes:
- Furniture Payment:
- Jewelry Payment:
- Boat and RV:
- How much money do you spend paying credit cards each month?:
- Have you incurred any credit card charges over $1,225.00 on any one credit card in the past six (6) months?
  
  YesNo
- Do you expect your income or expenses to change in the near future?
  
  YesNo
- Have you filed all of your income tax returns for this year and the past 3 years?
  
  YesNo
- Do you owe the IRS any past due taxes?
  
  YesNo
- Have you borrowed money from your IRA or other retirement plan to pay bills?
  
  YesNo
- Have you received any cash advances within the past 3 months?
  
  YesNo
- Are you leasing any buildings or equipment? (Storage Units)
  
  YesNo
- Does an ex-spouse have a claim against you for any reason?
  
  YesNo
- Do you owe money on the purchase of jewelry, furniture or other household goods?
  
  YesNo
- Are you in the process of suing someone?
  
  YesNo
- Does anyone want to sue you or have they already filed a lawsuit against you?
  
  YesNo
- Does anyone have a claim against you due to a car accident?
  
  YesNo
- During the past 2 years, have you owned or had an interest in any business?
  
  YesNo
- Have you transferred any property with a retail value of $600 or more within the past 4 years? (ex: homes, motor vehicles and other assets)
  
  YesNo
- Have you stopped using all your credit cards?
  
  YesNo
- Have you ever filed bankruptcy before?
  
  YesNo
- Are you behind in child support?
  
  YesNo
- Do you have any payday loans you still owe money for?
  
  YesNo
- Have you closed any bank accounts and left owing a balance?
  
  YesNo
- Do you have any bounced checks you owe additional fees for?
  
  YesNo
- Do you have any co-signers for your debts other than your spouse (if applicable)?
  
  YesNo
- Are you currently paying any court fines?
  
  YesNo
- Are your wages currently being (or are soon to be) garnished?
  
  YesNo
- Do you have any judgments against you from any lawsuits that you lost?
  
  YesNo
- Are you currently drawing unemployment, retirement and / or social security disability?
  
  YesNo
- Do you have CDs, stocks, bonds, or other types of financial accounts?
  
  YesNo
- Are you taking out cash advances on your credit cards to provide you with cash to pay essential living expenses?
  
  YesNo
- Is your license currently suspended?
  
  YesNo
- If yes, is it suspended because of unpaid tickets?
  
  YesNo
- If no, is it suspended because of a prior car accident?
  
  YesNo
- FAMILY HOUSEHOLD
- Have you been married before?
  
  YesNo
- If yes, did you agree to take on joint debt?
  
  YesNo
- If yes, are you living together or in separate households?
  
  TogetherSeparate
- STATEMENT OF ACCURACY
  By signing my/our names below, I/we state that the information in this ten (10) page Initial Intake Form is true and correct to the best of my/our knowledge. I/We understand that providing inaccurate information can detrimentally affect my/our case, cause an undue outcome or result in charges brought against me/us if convicted of fraud. I/We also understand the information provided in this Initial Intake Form will not be shared with any other party, other than attorneys who have the knowledge to legally advise me/us and authorized parties assigned by the attorneys to work on my/our case.
- Please sign Debtor 1: *
  Sign your name
- Please sign Debtor 2: *
  Sign your name
- THE END
- Follow up Notes
- Follow up Date
  
  MonthDayYear
- Should be Empty:

The Law Office of Jonathan Augusta

Income:

Assets & Accounts:

Mortgages:

Other Real Property

Vehicles

TAXES AND OTHER PRIORITY DEBTS

OTHER DEBTS

FAMILY HOUSEHOLD

THE END