Bankruptcy Questionaire Form

Sweeney Law Firm, P.C - Client Intake Form
Purpose for Visit?*

BankruptcyDebt WorkoutCivil Collection Lawsuit Defense
Date*

MonthDayYear
How did you find us?*

Google Search EngineADDirect Mail LetterReferral
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?

YesNo
If yes what chapter (7 or 13) and date filed?
Number of family members and others living with you (not including your wife)
Martial Status

SingleMarriedSeperatedDivorcedWidowed

Collapse this section if single
Spouse's Full Name

First 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
Current Employer?
Years?
Previous?
Has your spouse filed Bankruptcy in the past 8 years?

YesNo
What chapter (7 or 13) and what date?

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?

YesNo
Foreclosure sale date been set?

YesNo
Click to edit

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

YesNo
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?

YesNo
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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