BANKRUPTCY INTAKE FORM
Will this be a joint bankruptcy petition? If yes, include information for Husband and Wife; if no, include information only for
yourself.
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Will this be a joint bankruptcy petition? If yes, include information for Husband and Wife; if no, include information only for
yourself.
Husband's name & residence address
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How long at this address?
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Have you used any other name(s) in the last six years? If yes, please list here
Wife's name & residence address
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How long at this address?
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Have you used any other name(s) in the last six years (including maiden name)? If yes, please list here
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Please provide the names and ages of minor children living with you
How much do you pay in child support? Please list the name(s) of each child, age(s), and amount(s).
Please list previous addresses for the last two years
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Do you owe any money to the Internal Revenue Service?
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Do you owe any money to the Internal Revenue Service?
Do you owe any money to state tax authorities?
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Do you owe any money to state tax authorities?
Do you have any unpaid student loans?
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Do you have any unpaid student loans?
Please provide your income per pay period
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Please provide your income per pay period
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Have you received income from any other source than your job last year (for instance, social security, child support, workers' compensation, etc)? If yes, please provide the source and monthly amount here
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What amount of income have you made at your job as follows:
Do you pay anyone spousal support? (alimony)
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Do you pay anyone spousal support? (alimony)
How much is your car payment every month?
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Do you anticipate a substantial change in your expenses in the immediate future?
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Do you anticipate a substantial change in your expenses in the immediate future?
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? If yes, give name of business and/or corporation, dates of operation, nature of business/corporation, and your approximate yearly income from the business.
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Have you given away, sold or transferred any valuable item (over $1,000) in the last year? If yes, please state the nature of the sale or transfer, what was transferred, for how much, and when the transfer occurred.
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What amount of income have you received from other sources in the last two years?
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Will you be eligible for a tax refund this year?
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Will you be eligible for a tax refund this year?
Please list all banks with which you have an account, and indicate whether checking or savings, and the approximate balance.
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Untitled multiple choice field
Are you holding valuable property that belongs to another person?
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Are you holding valuable property that belongs to another person?
Have you had a prior bankruptcy?
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Have you had a prior bankruptcy?
Is any of your property in the hands of a receiver, trustee, or other liquidating agent?
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Is any of your property in the hands of a receiver, trustee, or other liquidating agent?
Are you suing anyone right now?
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Are you suing anyone right now?
Have you been involved in a workers' compensation or personal injury lawsuit from which you expect to recover money?
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Have you been involved in a workers' compensation or personal injury lawsuit from which you expect to recover money?
Have you had any repossessions in your past history?
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Have you had any repossessions in your past history?
Have you suffered any losses by fire, theft, or gambling during the last year?
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Have you suffered any losses by fire, theft, or gambling during the last year?
Please list the years in which your debt was incurred
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