PRELIMINARY BANKRUPTCY INTAKE INFORMATION

JOINT APPLICATION

Thank you so much for contacting our law office. Please read the privacy policy below, and then fill out this form in its entirety prior to our consultation.

Privacy Policy

All information received from a client is strictly confidential. Our firm takes every step possible to protect your privacy. The data submitted via this form is encrypted and secured using industry-standard 256-bit SSL encryption.

Your Social Security number and other personal information will only be used in the event that you hire the firm to represent you in your legal matter, and then only when necessary in limited use during the course of your case.

Social Security numbers are most often used to positively identify parties. Most courts require Social Security numbers of all parties in a case. Some other examples of how this information may be used include:

initial service
in court orders
in required reports or other documents filed with the State

If you have any questions, please don't hesitate to contact our law office. We look forward to working with you.

CONTACT INFORMATION

Contact Information: Contact 1

First Name

Last Name

Date of birth

Company

Emails

Email Address *

Upon submission, a copy of this form will be sent to this email.

Address

Street Address

Country

City

State/Region

Zip/Postal Code

Address Type

Phone Numbers

Phone Number *

Social Security Number:

How long have you lived at the address above?

Have you used any other name(s) in the last 8 years?

Yes

SPOUSE'S INFORMATION

Contact Information: Contact 2

First Name:

Middle Name:

Last Name:

Email:

Email Address:

Type

Address:

Street Address:

Country:

City:

State

Address:

Zip/Postal Code:

Type

Phone Number

Phone Number

Phone:

Social Security Number:

How long have you lived at the address above?

Has your spouse used any other name(s) in the last 8 years?

Yes

Including maiden names

Current Marital Status:

If you’ve been married, please give your date of marriage:

If your divorce, please provide your date of divorce:

Children

For each child, please select "Yes" and complete the requested information. If it's not applicable, please select "No".

Please provide the names and ages of minor children living with you:

Child 1:

Yes

Child 2:

Yes

Child 3:

Yes

Child 4:

Yes

If you are PAYING CHILD SUPPORT, please select "Yes" and complete the requested information. If it's not applicable, please select "No".

Child 1:

Yes

Child 2:

Yes

Child 3:

Yes

Child 4:

Yes

PREVIOUS ADDRESS(ES)

Please select "Yes" and complete the requested information about your previous address for the last two years. If it's not applicable, please select "No".

Address 1

Yes

Address 2

Yes

Address 3

Yes

MONEY OWING

Do you owe any money to the Internal Revenue Service?

Yes

Do you owe any money to state tax authorities?

Yes

Do you have any unpaid student loans?

Yes

EMPLOYMENT INFORMATION

Your Employer:

Salary:

How long at this job?

Occupation:

How often Paid? Example: Bi-weekly, Monthly, etc.

Please provide your income per pay period:

Gross:

Net:

SPOUSE'S EMPLOYMENT INFORMATION

Spouse's Employer:

Salary:

Occupation:

How long at this job?

Please provide your spouse's income per pay period:

How often Paid? Example: Bi-weekly, Monthly, etc.

Gross:

Net:

________________________________________________

Have you received income from any other source than your job last year?

Yes

For instance, social security, child support, workers' compensation, etc

How much money have you earned so far this year?

How much money has your SPOUSE earned so far this year?

How much money did you earn last year?

How much money did your SPOUSE earn last year?

If you have more than one job, please list year-to-date and two-years prior income information here:

MONTHLY EXPENSES

Please select "Yes" under each expense category and complete the requested information applicable to you.

HOME/ RENT:

Rent:

Real estate taxes:

Homeowner/rent insurance:

Home maintenance:

House Payment:

UTILITIES:

Electric:

Water:

Phone:

Laundry:

Trash:

TRANSPORTATION:

Car Expenses:

Auto Insurance:

ENTERTAINMENT & GROCERIES:

Entertainment:

Food:

Cable:

HEALTH CARE:

Life insurance:

Uninsured Medical:

Health Insurance:

OTHER:

Education:

Clothing:

Child care:

Other:

Do you each wish to keep your individual earnings separate?

Yes

_____________________________

Do you pay anyone spousal support?

Yes

How much is your car payment every month?

Car #1:

Car #2

Do you anticipate a substantial change in your expenses in the immediate future?

Yes

Have you been in a partnership with anyone during the last six years, or have you been an officer in a corporation within the last six years?

Yes

Have you given away, sold or transferred any valuable item (over $1,000) in the last year?

Yes

Will you be eligible for a tax refund this year?

Yes

BANKING INFORMATION

Please provide us with a list of all banks with which you have an account. Select "Yes" and complete the requested information. If it's not applicable or if you have finished providing us with the information, please select "No".

Bank 1

Yes

Bank 2

Yes

Bank 3

Yes

Bank 4

Yes

SAFE DEPOSIT

Have you had a safe deposit box in the last two years?

Yes

Are you holding valuable property that belongs to another person?

Yes

OTHER INFORMATION

Have you ever filed for bankruptcy before?

Yes

Are you suing anyone right now?

Yes

Have you been involved in a workers' compensation or personal injury lawsuit from which you expect to recover money?

Yes

Have you had any repossessions in your past history?

Yes

Have you suffered any losses by fire, theft, or gambling during the last year?

Yes

Please list the years in which your debt was incurred: (approximate range) _________ to __________

Do you own a business?

Yes

Do you have any inheritances that you will be receiving?

Yes

THANK YOU

We will contact you as soon as possible.

Please click the SUBMIT button when you have finished completing this form.