BANKRUPTCY INTAKE FORM

Name

First Name

Last Name

Phone

(###)

###

####

What County do you live in?

Marital Status

If married how will you be filing?

Do you have any children?

Yes

If you do have children how much do you pay in child support per month?

What is your estimated amount of debt?

Do you owe debt to the IRS ?

Yes

What type of bankruptcy are you interested in filing?

Have you filed bankruptcy in the past eight years?

Yes

Gross Monthly Income

Monthly Expenses

Please do not include expenses you are trying to write-off in filing bankruptcy.

If you have a roommate or live in partner please only include the expenses that you pay for per month.

If you are married and filing single, please note the non-filing's spouse income and expenses must be included in your monthly income and expenses breakdown below.

Please list all of your monthly expense i.e. rent, utilities, vehicle payment/insur., vehicle maintenance/registration, gasoline, phone/internet, food, chartiable contributions, all related living expenses (per month).

To qualify for a Chapter 7 filing your gross monthly income must be lower than your monthly expenses. After adding up all of your monthly expenses does the amount exceed your income?

If you have a mortgage, are you and your spouse’s name on the mortgage and deed? If not whose name is on the deed and mortgage note?

Mortgage

Have you gifted any money to anyone within the past two years?

If so who and was it over $600? Please describe below

Have you received a personal loan from a family member or friend in the past six months?

Please state below if you paid the loan back and if so when was it paid back?

Have you lived in your present state less than 2 years?

Determine state residency.

Are you facing an eviction or expect to be evicted from your rental unit soon?

Yes

Do you receive Social Security, Medicaid or Medicare?

Please let us know if you receive any government assisted services.