NEW CLIENT INFORMATION FORM

  • Joseph A. Ross NEW CLIENT INFORMATION FORM

  • 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!

  • Date:
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  • Marital Status
  • Date of Birth:
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  • Spouse Date of Birth:
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  • Do you Have Children That Live at Home?
  • Do You Have Children That Do Not Live with You?
  • Have you been to see us before?
  • How did you find out about our office?

  • PRELIMINARY QUESTIONNAIRE

  • 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!

  • 1. Have you ever filed bankruptcy before?
  • 2. Have you live OUTSIDE of Indiana at any time in the past 2 years?
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  • From ANY OTHER SOURCE besides wages from employment?
  • 4. Do you expect to receive any money or property from sources like those described in Question 3 within the next 12 months?
  • 5. Do you have any lawsuit or personal injury claims that you have filed or that you could file against anyone else?
  • 6. Does any person or company owe you money for anything?
  • 7. Do you pay any one creditor at least $200 per month every month (such as a house payment, car payment, etc.)?
  • 8. Have you paid any one creditor $600.00 or more in an irregular payment over the past 3 months? (Such as catching a loan up or paying a loan off)
  • 9. Have you paid any friend or family member any money, either as a loan, a gift, or paying them back money you borrowed, within the past 12 months?
  • 10. Have you sold or transferred any property within the past 24 months, such as sold or quitclaimed a house, traded in a car, etc.?
  • 11. Do you own a business?
  • 12. Have you been divorced in the past, or are you in the middle of a divorce?
  • 13. Have you been sued by anyone, or could you be sued by anyone that you are aware of, for any claims other than collections lawsuits?
  • 14. Have you been sued by anyone, or could you be sued by anyone that you are aware of, for any claims related to Fraud, battery, theft, or other intentional acts?
  • 15. Have you written any bad checks that are not yet paid?
  • 16. Have you been sued by anyone, or could you be sued by anyone that you are aware of, for any claims related to an accident in which you were accused of being under the influence of drugs or alcohol?
  • 16a. Does the landlord of the premises in which you reside have a judgement against you for possession of the rental premises?
  • 17. Do you have any lawsuits or judgments against you now?
  • 18. Are your wages being garnished at this time?
  • 19. Do you own or are you buying a house, condo, mobile home, or any other real estate, or is your name on anyone else's deed to real estate?
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  • 20. Did any creditors use property you already owned, such as furniture, household goods, or a vehicle, as collateral for a new loan?
  • 21. Do you owe any unpaid taxes on real estate?
  • 22. Do you owe any back income, or withholding taxes?
  • 23. Do you pay child support or alimony to anyone?
  • If so, are payments current?
  • 24. Do you have any student loans?
  • 25. Do you owe any wages to any employees?
  • 26. Do you owe any criminal fines?
  • 27. Has anyone paid you to do any jobs you have not finished?
  • 27(A). Do you owe any 401(k)/Retirement loan?
  • 28. Do you have a pension or retirement?
  • 29. Did you get a tax refund check this year, or do you still expect one?
  • 30. Do you have a checking or savings account?
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  • 32. Are you a co-signer for anyone else, or has anyone else co-signed for you, on any loans that are not yet paid in full?

  • 33.  Regarding your income:

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  • 35. Have you used any credit card, got a cash advance, did a balance transfer, or bought anything else on a credit card within the last 90 days?
  • 36. Have you broken an apartment or a rental lease?
  • 37. Have you had a vehicle repossessed?
  • 38. Have you been in any traffic accident or other accidents in which you did not have insurance?
  • 39. Do you have car insurance now?
  • 40. Have you ever paid for income, withholding, or sales tax liability with a credit card?
  • 41. Do you own or have possession of any property that poses or is alleged to pose a threat of imminent and identifiable harm to the public health or safety?
  • Do you expect to have any medical procedures in the future which insurance will not cover?
  • 43. If you decide to file bankruptcy, do you intend to file alone or jointly with your spouse?

  • YOUR MONTHLY EXPENSES

  • 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.

     

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  • 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.

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