Bankruptcy Intake Form

Client Intake Form
Purpose for Visit? *

Bankruptcy Debt Civil Estate
Date *

Month Day Year
How did you find us? *

Arag Search Engine AD
Plan Id:
Will or Trust - No Cost Arag

Yes No Unsure
Full Name *

First Name Last Name
Social Security Number #
Birth Date

Month Day Year
Address *

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code Country
Phone Number *

Area Code Phone Number
Cell/Work

Area Code Phone Number
E-mail *
Current Employer?
Years?
Previous?
Have you filed Bankruptcy in the past 8 years?

Yes No
What chapter?
Number of family members and others living with you (not including your wife)
Martial Status

Single Married Seperated Divorced Widowed

Collapse this section if single
Spouse's Full Name

First Name Last Name
Spouse's Social Security #
Birth Date

Month Day Year
Gender

Male Female
Spouse's Address

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code Country
Spouse's Phone Number

Area Code Phone Number
Current Employer?
Years?
Previous?
Has your spouse filed Bankruptcy in the past 8 years?

Yes No
What chapter?

Collapse if no other real property
Payment/Mo - 1st
Delinquent - 1st
Total Debt - 1
Payment/Mo -2nd
Delinquent - 2nd
Total Debt - 2
Property in foreclosure?

Yes No
Foreclosure sale date been set?

Yes No
Click to edit

Month Day Year
Is your name on the deed of any other house, bare land, time share or burial plot?

Yes No
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?

Yes No
Notes:
TAXES AND OTHER PRIORITY DEBTS

Collapsable
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:

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