Bankruptcy Intake Form

***We will review your information and respond within the next 1 to 2 business days***

Name ,

Marital Status Choose One Single Married Divorced Separated

If married, what is spouse's name

,

If married, do you plan to file bankruptcy as an individual, or jointly with your spouse?

Individual Jointly Not Sure Choose One (if married)

 How many people are in your household that you must support?

(include yourself & your spouse)   

Address    , FL

What county do you reside in?

County Choose One Brevard Broward Charlotte Collier Desoto Glades Hardee Hendry Hernando Hillsborough Lake Lee Manatee Monroe Palm Beach Miami-Dade Orange Osceola Pasco Pinellas Polk Sarasota Seminole

Home Phone      Work Phone     

Mobile Phone E-Mail

Where did you hear about us?

Internet Google Search Non-Google Search Friend/Relative Prior Client Other Choose One    

How much debt do you have not counting vehicles or mortgages?  

  $

How many creditors do you believe that you have?

If you have credit card debt, when was the last time you charged?

What is your monthly household net income (after taxes, take home income)?

(Include spouse's income even if you intend to file individually)

You    $        Spouse    $

Do you own any vehicles?     YES          NO

If you answered "YES" above complete the following information:

Vehicle 1 , ,     

Fair Market Value   $ Balance Owed   $     

Monthly Payment   $

What are your intentions with this vehicle? Keep Vehicle Surrender Vehicle Choose One

Vehicle 2 , ,    

 Fair Market Value   $ Balance Owed   $     

Monthly Payment   $

What are your intentions with this vehicle? Keep Vehicle Surrender Vehicle Choose One

Vehicle 3 , ,     

Fair Market Value   $  Balance Owed  $     

Monthly Payment  $

What are your intentions with this vehicle? Keep Vehicle Surrender Vehicle Choose One

Real Estate

Do you own any real estate?     YES          NO

If you answered "YES" above complete the following information:

What are your intentions with this real estate? Keep Home Surrender Home Choose One

Purchase Date      Purchase Price $

Have you refinanced in the last two years?     YES          NO

How many mortgages do you have on your property?

How much is owed on each mortgage?    

First Mortgage   $       Second Mortgage   $      

Third Mortgage   $

What do you think you could sell the home for if you wanted to?  

$

Have you sold or transferred any real estate in the last four years?

YES NO

Other Assets

Describe any other assets you own that have significant value

Description

Approx. Value $

Description

Approx. Value $

Description

Approx. Value $

Taxes

What did you show for taxable income on your most recent tax return (AGI)?

$

Do you owe the IRS or state for back taxes?   

   YES          NO

Are there any years for which you have not filed state or federal income tax returns?    

YES          NO     

If yes, what years?

Did you get a tax refund last year?    

YES          NO     

If yes, how much?   $

Additional Information

Have you ever filed bankruptcy before?    YES          NO   

If yes, what year?      what chapter Chapter 7 Chapter 13

In the last two years have you given or paid more than $500 to any friend or relative?    

YES          NO

Does anyone owe you any money? YES NO Amount $

Have creditors been calling you at home or work?     

 (Home)    YES       NO        (Work)    YES     NO

Have you been served with a summons in the last year?    

YES          NO

Have you been involved in a law suit in the last year? YES        NO

If you answered yes above, please give brief description on the law suit:

Are your wages being garnished?     YES          NO

Are you behind on your home and/or car payment?     YES          NO

Will you have trouble obtaining the address of any of your creditors?    

YES          NO

Do you own a business? YES        NO

If yes, please give brief description of business:

What do you pay monthly for the following (approximately)?

Is there any additional information that may be relevant to your case?

Are there any questions that you need an answer for right now?

After completing this form, please click this "Submit" button: 

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