New Bankruptcy and Debt Relief Client Intake Form

Your First Name

Your Last Name

Phone Number

Email Address

Are you employed?
YesNo

If yes, How much do you estimate that you gross per month at your job? (Gross, Per Month)
Less than $2000$2000-$3000$3000-$4000$5000-$6000Over $6000

Marital Status
MarriedNever MarriedDivorcedWidowed

If married, is your spouse employed?
YesNo

If yes, how much does he/she make at his/her job? (Gross, Per Month)
less than $2000$2000-$3000$3000-$4000$5000-$6000over $6000

Do you or your spouse have other income from any other source? (Multiple Choice)
UnemploymentChild SupportRetirementSocial SecurityDisabilityother

If yes, how much? (Gross, Per Month)
less than $1000$1000- $2000$2000-$3000$3000-$4000$5000-$6000over $6000

How many dependents do you have?

Do you owe the IRS, or will you owe for any currently unfiled tax returns?
YesNo

Do you have a mortgage payment or a car payment?
YesNo

If yes, are you more than 30 days behind on either payment?
YesNo

Are you being sued by a creditor or anyone else, or have you been sued and lost (if there is already an existing judgment against you)?
YesNo

Approximately how many credit cards/unsecured loans do you have?
1-1011-2021-4041-50