Intake Form (BK)

Intake Form

Please complete to the best of your ability.
Personal & Contact Information
First Name
Middle Name
Last Name
Date of Birth

MonthDayYear
Date
Street Address
Apt / Unit
City
State
ZIP Code
Cell Phone
Please enter a valid phone number.Format: (000) 000-0000.
Alternate Phone
Please enter a valid phone number.Format: (000) 000-0000.
Email Address
example@example.com
Preferred contact method
Household & Employment
Marital Status
Are you filing jointly with a spouse?
Spouse's Name
Number of Dependents
Employment Status
Employer
Occupation
Gross Monthly Income (Household)
Household Size
Other Sources of Income
Bankruptcy History & Course
Have you filed for bankruptcy before?
If yes, when and which chapter?
Which type are you interested in (if known)?
Have you completed a credit counseling course?
Debt, Triggers & Urgency
What is leading you to consider bankruptcy?

Other
Are you facing any of these now?

Other
Is there an upcoming foreclosure sale, repossession, or garnishment date?
If yes, what is the date?

MonthDayYear
Date
Assets, Debts & Financial Obligations
Do you own a home?
Approx. home value
Approx. mortgage balance
Are you behind on mortgage payments?
Do you own one or more vehicles?
How many vehicles?
Vehicle 1
Year, Make, and Model
Color
Mileage
Approximate value of the vehicle
Is money owed on this vehicle?
Approximately how much is owed?
Vehicle 2
Year, Make, and Model
Color
Mileage
Approximate value of the vehicle
Is money owed on this vehicle?
Approximately how much is owed?
Vehicle 3
Year, Make, and Model
Color
Mileage
Approximate value of the vehicle
Is money owed on this vehicle?
Approximately how much is owed?
Vehicle 4
Year, Make, and Model
Color
Mileage
Approximate value of the vehicle
Is money owed on this vehicle?
Approximately how much is owed?
Are any vehicles financed and behind on payments?
Other significant assets
Approx. total unsecured debt
Do you owe back taxes?
Do you have any co-signed debts?
Additional Information and Referral
Briefly state any additional information you believe we should know.
How did you hear about us?

Other
Referred by (name)
☎Call Us

🌐Webpage
Should be Empty:

Intake Form

Personal & Contact Information

Household & Employment

Bankruptcy History & Course

Debt, Triggers & Urgency

Assets, Debts & Financial Obligations

Vehicle 1

Vehicle 2

Vehicle 3

Vehicle 4

Additional Information and Referral