Bankruptcy Intake Form

Client Intake Form
Purpose for Visit?
Date

MonthDayYear
How did you find us?

Other
Plan Id:
Will or Trust - No Cost Arag
Full Name

First NameLast Name
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
Current Employer?
Years?
Previous?
Have you filed Bankruptcy in the past 8 years?
What chapter?
Number of family members and others living with you (not including your wife)
Martial Status
- Spouse's Full Name
  
  First NameLast Name
- Spouse's Social Security #
- Birth Date
  
  MonthDayYear
- Gender
- Spouse's Address
  
  Street Address
  
  Street Address Line 2
  
  CityState / Province
  
  Postal / Zip CodeCountry
- Spouse's Phone Number
  
  Area CodePhone Number
- Current Employer?
- Years?
- Previous?
- Has your spouse filed Bankruptcy in the past 8 years?
- What chapter?
- Income:
- How often paid?
- Average Takehome paycheck
- Your average Gross Paycheck per payday
- Average Takehome paycheck
- Spouse's average Gross Paycheck per payday
- How often paid?
- Retirement / Pension / Social Security per mo
- Self Employed/ Business Net profit per mo
- Other Income
- Notes:
- Mortgages:
  
  Please list your home and any other house, bare land or time share where your name is on the deed.
- Rent or Own
- Eppraisal Zillow
- Payment/Mo - 1st
- Delinquent - 1st
- Total Debt - 1
- Payment/Mo -2nd
- Delinquent - 2nd
- Total Debt - 2
- Property in foreclosure?
- Foreclosure sale date been set?
- Click to edit
  
  MonthDayYear
- Notes:
- Other Real Property
- Payment/Mo - 1st
- Delinquent - 1st
- Total Debt - 1
- Payment/Mo -2nd
- Delinquent - 2nd
- Total Debt - 2
- Property in foreclosure?
- Foreclosure sale date been set?
- Click to edit
  
  MonthDayYear
- Is your name on the deed of any other house, bare land, time share or burial plot?
- Notes:
- Vehicles
  
  Please list all cars, trucks, motorcycles, boats or aircraft where your name is on the registration.
- 1st Estimated Value
- Kelly Blue Book
- 1st Vehicle Model Year
- Auto Maker
- Model
- Payment/Mo
- Delinquent
- Total Debt
- Mileage
- 2nd Estimated Value
- 2nd Vehicle Model Year
- Auto Maker
- Model
- Payment/Mo
- Payment/Mo
- Total Debt
- Mileage
- 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?
- Notes:
- 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
- Notes:
- 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?
- Have you used one card to pay another?
- Do you have a checking account at a bank that issued the card?
- Total Medical debt
- Total Student loans:
- Law Suit/Judgement
- Total Personal Loans:
- Total Credit Union Loans:
- Total loans from family:
- Notes:
- THE END
- Retained Client?
- Follow up Notes
- Follow up Date
  
  MonthDayYear
- Should be Empty:

Client Intake Form

Income:

Mortgages:

Other Real Property

Vehicles

TAXES AND OTHER PRIORITY DEBTS

OTHER DEBTS

THE END