Welcome! In order to serve you better, we need some basic information. Please fill out the information below and hit Submit at the end and we will call you to discuss! Thank you!

Please answer all of the questions below by checking either “Yes” or “No,” fill in the blanks where applicable, and sign and date where indicated. Please be as accurate as you can. Thank you!

33.  Regarding your income:

Please give the average MONTHLY amounts you spend OUT-OF-POCKET on each of the items below. Do NOT include things paid by insurance, deducted from your paycheck, etc. Please be as accurate as possible, though we understand many of these figures will simply be your best estimate.

I UNDERSTAND THAT THIS LAW OFFICE DOES NOT REPRESENT ME AND THAT NO ATTORNEY-CLIENT RELATIONSHIP HAS BEEN OR WILL BE FORMED UNTIL I HAVE PAID THE ATTORNEYS FEES IN FULL, PROVIDED ALL DOCUMENTS REQUESTED, SIGNED MY BANKRUPTCY PETITION, AND MY BANKRUPTCY IS FILED WITH THE BANKRUPTCY COURT.  IT IS MY RESPONSIBILITY TO CONTACT THIS LAW OFFICE AFTER TODAY’S CONSULTATION IF I DECIDE TO RETAIN THEIR SERVICES.  I UNDERSTAND THAT ALL MONIES I PAY TO THIS OFFICE ARE NON-REFUNDABLE TO THE EXTENT THAT WORK IS PERFORMED ON MY CASE, BUT AMOUNTS NOT EARNED FOR WORK ON MY CASE WILL BE REFUNDED TO ME IF I LATER DECIDE NOT TO FILE MY CASE.  FEES PAID WILL BE EXPENDED AT THE RATE OF $150 TO START FILE AND $50/MO TO MAINTAIN MY FILE PLUS ANY OTHER WORK PERFORMED ON MY CASE.  FEES QUOTED TO ME ARE GOOD FOR 90 DAYS. 

I HEREBY WAIVE ALL CONFLICT OF INTEREST CLAIMS, PRESENT AND FUTURE, IN RETURN FOR THIS CONSULTATION AND CASE EVALUATION. 

 I AFFIRM THAT THE ABOVE ANSWERS ARE TRUE AND COMPLETE TO THE BEST OF MY KNOWLEDGE AND BELIEF.