Bankruptcy Information Form In order to assist us in arriving at a solution to your debt problems, please complete the following new client information form. Our bankruptcy practice is made up of experienced team members who look forward to helping you solve your financial situation. Approximate numbers are fine – Just give your best estimates on all information. Step 1 of 8 12% DEBTOR (Husband, if married)Name First Middle Last Suffix Aliases or Former NameEmail Have you ever filed a bankruptcy?Please SelectYesNoSocial Security NumberCell # (Home # if no cell)If so, when?Birth Date Date Format: MM slash DD slash YYYY Work PhoneWhat Chapter?Please SelectChapter 13Chapter 7BothUnsureCO-DEBTOR (Wife, if married)Name First Middle Last Suffix Aliases or Former NameEmail Have you ever filed a bankruptcy?Please SelectYesNoSocial Security NumberCell # (Home # if no cell)If so, when?Birth Date Date Format: MM slash DD slash YYYY Work PhoneWhat Chapter?Please SelectChapter 13Chapter 7BothUnsureCONTACT INFORMATIONAddress Street Address Address Line 2 City AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code CountyHave you lived here more than 90 days?Please SelectYesNoAddress Street Address Address Line 2 City AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code How did you hear about us?Internet SearchNOLOForeclosure LetterYellow PagesTV CommercialReferral RESIDENCE / REAL ESTATEDo you own or rent your primary residence?Please SelectOwnRentName of LandlordLandlord PhoneAre you behind on rent? If so, how much?Landlord AddressHOMESTEADIf you own your home, and it has debt such as mortgage loans, home equity loan, home equity line of credit, homeowner’s association dues or assessments, property taxes or IRS liens please provide the following information:Address of Property Street Address Address Line 2 City AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Do you want to keep this home?Please SelectYesNoUncertainCurrent Market ValueFIRST MORTGAGE - Mortgage CompanyAttorney for First Mortgage (if known)Balance on First MortgageMonthly Payment - First MortgageArrearage ($ Behind) - First MortgageHow many months behind? (First Mtg)SECOND MORTGAGE - Mortgage CompanyAttorney for Second Mortgage (if known)Balance on Second MortgageMonthly Payment - Second MortgageArrearage ($ Behind) - Second MortgageHow many months behind? (Second Mtg)Are you behind on homeowner's association dues or property taxes or do you have an IRS lien on your home? If so, please explain in detail:Do you own any other properties?Please SelectYesNoProperty Address Have you owned any other properties in the last four years?Please SelectYesNoIf so, please provide details including sale date and amount: VEHICLESDo you or your spouse have any vehicles titled in your name(s)?Please SelectYesNoVEHICLE #1 Year / Make / ModelApproximate Miles (1)Purchase Date Date Format: MM slash DD slash YYYY Lease/Financed?Please SelectFinancedLeasedPaid OffLender NameApprox BalanceMonthly Payment$ Past DueDo you want to keep this vehicle?Please SelectYesNoUncertainVEHICLE #2 - Year / Make / ModelApproximate Miles (2)Purchase Date Date Format: MM slash DD slash YYYY Lease/Financed?Please SelectFinancedLeasedPaid OffLender NameApprox BalanceMonthly Payment$ Past DueDo you want to keep this vehicle?Please SelectYesNoUncertainVEHICLE #3 - Year / Make / ModelApproximate Miles (3)Purchase Date Date Format: MM slash DD slash YYYY Lease/Financed?Please SelectFinancedLeasedPaid OffLender NameApprox BalanceMonthly Payment$ Past DueDo you want to keep this vehicle?Please SelectYesNoUncertainIf you have any other vehicles titled in your name please list (same information as above)Have you transferred any vehicles out of your name in the past year? If so, please listRECREATIONAL VEHICLESDo you own any recreational vehicles? (Motorcycles, boats, trailer, ATV etc)Please SelectYesNoIf so, please provide details (type, financing, arrears etc) RETIREMENT ACCOUNTS401(k)Please SelectYesNoIRAPlease SelectYesNoAnnuityPlease SelectYesNoProfit SharingPlease SelectYesNoStocksPlease SelectYesNoBondsPlease SelectYesNoEmployerPlease SelectYesNoEducational IRAPlease SelectYesNoTerm Life InsurancePlease SelectYesNoWhole Life InsurancePlease SelectYesNoAny other investments?Please SelectYesNoAmountAmountAmountAmountAmountAmountAmountAmountAmountAmountUntitledOTHER ASSETSAre you suing or have a claim against anyone for personal injury, car wreck, employment case or any other reason?Please SelectYesNoIf so, please provide detailsDo you expect a tax refund this year?Please SelectYesNoUncertainIf yes, how much?Please list any assets not previously discussed - collections, art, firearms, jewelry, luxury items etc.Do you have any inheritances pending?Please SelectNoYesIf so, please give details:Do you or your spouse own (or have owned in the last 6 years) a business? (Including self-employed with no employees)Please SelectYesNoBusiness Structure Corporation Sole Proprietor LLC Name of BusinessBeginning Date of Business Date Format: MM slash DD slash YYYY Nature of BusinessEnding Date of Business (if closed) Date Format: MM slash DD slash YYYY Business Bank BalanceBusiness InventoryBusiness Debt DEBTPlease provide estimates of your debt for each of the below categories. You will be asked to provide more information after your initial consultation; therefore, it is understood that the figures you provide today may change prior to completing your legal documents.Credit Card DebtLast date you used any credit cards Date Format: MM slash DD slash YYYY Medical BillsRepossession DebtDate of Repossession Date Format: MM slash DD slash YYYY Foreclosure DebtWage GarnishmentsIRS DebtPersonal LoansCash Advances/Payday LoansReturned ChecksProperty TaxesChild Support ArrearsStudent LoansJudgmentsBusiness DebtsDebtor - I have filed my taxes for: Select All 2019 2018 2017 2016 2015 Co-Debtor - I have filed my taxes for: Select All 2019 2018 2017 2016 2015 Please explain any other debts not listed: INCOMEDebtor - Current EmploymentCurrent EmployerHow long employed?Take home pay from each paycheck:I get paid:Please SelectMonthlyWeeklyEvery 2 WeeksTwice per monthDebtor - Additional EmploymentSecond Job EmployerHow long employed?Take home pay from each paycheck:I get paid:Please SelectMonthlyWeeklyEvery 2 WeeksTwice per monthAny other income? Please specify:Co-Debtor - Current EmploymentCurrent EmployerHow long employed?Take home pay from each paycheck:I get paid:Please SelectMonthlyWeeklyEvery 2 WeeksTwice per monthCo-Debtor - Additional EmploymentSecond EmployerHow long employed?Take home pay from each paycheck:I get paid:Please SelectMonthlyWeeklyEvery 2 WeeksTwice per monthAny other income? Please specify:BANKING INFORMATIONDebtor Only AccountsAccounts ONLY in Debtor's NameChecking BalanceSaving BalanceOther Acct BalanceCo-Debtor Only AccountsAccounts ONLY in Co-Debtor's NameChecking BalanceSaving BalanceOther Acct BalanceJoint AccountsAccounts owned jointly by Debtor and Co-DebtorChecking BalanceSaving BalanceOther Acct Balance EXPENSESDependent ChildrenName and ages of dependent child(ren) and other dependents you can claim on tax returnsNameRelationAgeNameRelationAgeNameRelationAgeNameRelationAgeNameRelationAgeIf you have more than 5 dependents, please provide additional details here:Monthly ExpensesRent/Mortgage PaymentReal Estate Taxes Included?Please SelectYesNoUnsureHomeowner's Insurance Included?Please SelectYesNoUnsureSecond Mortgage PaymentElectricityWater / Sewer / GarbageTelephoneOther Utility (cable, internet etc)FoodClothingLaundry/Dry CleaningMedical/Dental (Not covered by insurance)Transportation(Gas, public transit)Recreation & EntertainmentInsuranceVehicle PaymentsAlimony / Child Support PaymentsNewspaper / MagazinesBabysitting / Child CareOther Expenses DOCUMENTSPlease upload any documents you wish to share with us for your appointment. This can include paystubs (helpful), foreclosure notices, lawsuits, judgments etc)FileFileFileFileTHANK YOU!Thank you for taking the time to complete this questionnaire. This will allow us to give you more accurate and helpful guidance and analysis of your options.NameThis field is for validation purposes and should be left unchanged.
