New Client Information Form - Leinart Law Firm

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

DEBTOR (Husband, if married)
Name
First Middle Last Suffix
- Aliases or Former Name
- Email
- Have you ever filed a bankruptcy?
- Social Security Number
- Cell # (Home # if no cell)
- If so, when?
- Birth Date
  MM slash DD slash YYYY
- Work Phone
- What Chapter?
CO-DEBTOR (Wife, if married)
Name
First Middle Last Suffix
- Aliases or Former Name
- Email
- Have you ever filed a bankruptcy?
- Social Security Number
- Cell # (Home # if no cell)
- If so, when?
- Birth Date
  MM slash DD slash YYYY
- Work Phone
- What Chapter?
CONTACT INFORMATION
Address
Street Address Address Line 2 City State ZIP Code
- County
- Have you lived here more than 90 days?
Address
Street Address Address Line 2 City State ZIP Code
How did you hear about us?
- Internet Search
- NOLO
- Foreclosure Letter
- Yellow Pages
- TV Commercial
- Referral

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RESIDENCE / REAL ESTATE
- Do you own or rent your primary residence?
- Name of Landlord
- Landlord Phone
- Are you behind on rent? If so, how much?
- Landlord Address
HOMESTEAD
If 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 State ZIP Code
- Do you want to keep this home?
- Current Market Value
- FIRST MORTGAGE - Mortgage Company
- Attorney for First Mortgage (if known)
- Balance on First Mortgage
- Monthly Payment - First Mortgage
- Arrearage ($ Behind) - First Mortgage
- How many months behind? (First Mtg)
- SECOND MORTGAGE - Mortgage Company
- Attorney for Second Mortgage (if known)
- Balance on Second Mortgage
- Monthly Payment - Second Mortgage
- Arrearage ($ Behind) - Second Mortgage
- How 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?
Property Address
Have you owned any other properties in the last four years?
If so, please provide details including sale date and amount:

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VEHICLES
Do you or your spouse have any vehicles titled in your name(s)?
- VEHICLE #1 Year / Make / Model
- Approximate Miles (1)
- Purchase Date
  MM slash DD slash YYYY
- Lease/Financed?
- Lender Name
- Approx Balance
- Monthly Payment
- $ Past Due
- Do you want to keep this vehicle?
- VEHICLE #2 - Year / Make / Model
- Approximate Miles (2)
- Purchase Date
  MM slash DD slash YYYY
- Lease/Financed?
- Lender Name
- Approx Balance
- Monthly Payment
- $ Past Due
- Do you want to keep this vehicle?
- VEHICLE #3 - Year / Make / Model
- Approximate Miles (3)
- Purchase Date
  MM slash DD slash YYYY
- Lease/Financed?
- Lender Name
- Approx Balance
- Monthly Payment
- $ Past Due
- Do you want to keep this vehicle?
If 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 list
RECREATIONAL VEHICLES
Do you own any recreational vehicles? (Motorcycles, boats, trailer, ATV etc)
If so, please provide details (type, financing, arrears etc)

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RETIREMENT ACCOUNTS
- 401(k)
- IRA
- Annuity
- Profit Sharing
- Stocks
- Bonds
- Employer
- Educational IRA
- Term Life Insurance
- Whole Life Insurance
- Any other investments?
- Amount
- Amount
- Amount
- Amount
- Amount
- Amount
- Amount
- Amount
- Amount
- Amount
Untitled
OTHER ASSETS
Are you suing or have a claim against anyone for personal injury, car wreck, employment case or any other reason?
If so, please provide details
Do you expect a tax refund this year?
If yes, how much?
Please list any assets not previously discussed - collections, art, firearms, jewelry, luxury items etc.
- Do you have any inheritances pending?
- If 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)
Business Structure
- Corporation
- Sole Proprietor
- LLC
- Name of Business
- Beginning Date of Business
  MM slash DD slash YYYY
- Nature of Business
- Ending Date of Business (if closed)
  MM slash DD slash YYYY
- Business Bank Balance
- Business Inventory
- Business Debt

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INCOME
- Debtor - Current Employment
- Current Employer
- How long employed?
- Take home pay from each paycheck:
- I get paid:
- Debtor - Additional Employment
- Second Job Employer
- How long employed?
- Take home pay from each paycheck:
- I get paid:
- Any other income? Please specify:
- Co-Debtor - Current Employment
- Current Employer
- How long employed?
- Take home pay from each paycheck:
- I get paid:
- Co-Debtor - Additional Employment
- Second Employer
- How long employed?
- Take home pay from each paycheck:
- I get paid:
- Any other income? Please specify:
BANKING INFORMATION
- Debtor Only Accounts
  Accounts ONLY in Debtor's Name
- Checking Balance
- Saving Balance
- Other Acct Balance
- Co-Debtor Only Accounts
  Accounts ONLY in Co-Debtor's Name
- Checking Balance
- Saving Balance
- Other Acct Balance
- Joint Accounts
  Accounts owned jointly by Debtor and Co-Debtor
- Checking Balance
- Saving Balance
- Other Acct Balance

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EXPENSES
Dependent Children
Name and ages of dependent child(ren) and other dependents you can claim on tax returns
- Name
- Relation
- Age
- Name
- Relation
- Age
- Name
- Relation
- Age
- Name
- Relation
- Age
- Name
- Relation
- Age
If you have more than 5 dependents, please provide additional details here:
Monthly Expenses
Rent/Mortgage Payment
Real Estate Taxes Included?
Homeowner's Insurance Included?
Second Mortgage Payment
Electricity
Water / Sewer / Garbage
Telephone
Other Utility (cable, internet etc)
Food
Clothing
Laundry/Dry Cleaning
Medical/Dental (Not covered by insurance)
Transportation
(Gas, public transit)
Recreation & Entertainment
Insurance
Vehicle Payments
Alimony / Child Support Payments
Newspaper / Magazines
Babysitting / Child Care
Other Expenses

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DOCUMENTS
Please upload any documents you wish to share with us for your appointment. This can include paystubs (helpful), foreclosure notices, lawsuits, judgments etc)
- File
  Max. file size: 50 MB.
- File
  Max. file size: 50 MB.
- File
  Max. file size: 50 MB.
- File
  Max. file size: 50 MB.
THANK 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.
Phone
This field is for validation purposes and should be left unchanged.

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Bankruptcy Information Form

Step 1 of 8

DEBTOR (Husband, if married)

CO-DEBTOR (Wife, if married)

CONTACT INFORMATION

RESIDENCE / REAL ESTATE

HOMESTEAD

VEHICLES

RECREATIONAL VEHICLES

RETIREMENT ACCOUNTS

OTHER ASSETS

DEBT

INCOME

Debtor - Current Employment

Debtor - Additional Employment

Co-Debtor - Current Employment

Co-Debtor - Additional Employment

BANKING INFORMATION

Debtor Only Accounts

Co-Debtor Only Accounts

Joint Accounts

EXPENSES

Dependent Children

Monthly Expenses

DOCUMENTS

THANK YOU!