Bankruptcy Intake Form

Bankruptcy Intake Questionnaire

Please complete each section as accurately as possible. This form does not collect full Social Security numbers. Document uploads will be handled separately through the client portal.

Step 1 - Contact & Filing Information

How Did You Hear About Us?

Debtor First Name

Debtor Middle Name

Debtor Last Name

Debtor Last 4 Digits of SSN

Debtor Date of Birth

Debtor Phone Number

Debtor Email Address

Marital Status

Are you filing jointly with your spouse?

Yes

Co-Debtor First Name

Co-Debtor Middle Name

Co-Debtor Last Name

Co-Debtor Last 4 Digits of SSN

Co-Debtor Date of Birth

Co-Debtor Phone Number

Co-Debtor Email Address

Step 2 - Residence & Household

Current Street Address

Current City

Current ZIP Code

Unit/Apt #

Current State

County of Residence

Residence Type

Years at Current Address

Additional Months at Current Address

Have you lived anywhere else within the last 3 years?

Yes

Previous Addresses Within Last 3 Years

Previous Street Address	Previous Unit/Apt #	Previous City	Previous State	Previous ZIP	Previous County	Lived There From	Lived There To

Total Household Size

Do you have dependents?

Yes

Dependents

Relationship	Age	Lives With You?
		Yes No Shared Custody / Part-Time

Step 3 - Bankruptcy Background

Have you filed bankruptcy within the last 8 years?

Yes

Who Filed?

Chapter Filed

Approximate Filing Date

Have you filed all required tax returns for the previous 2 years?

Yes

Not Sure

Unfiled Tax Returns

Tax Year	Tax Return Type

Is there a Court Order requiring you to pay child support, alimony, or another domestic support obligation?

Yes

Domestic Support Obligations

Type	Recipient Name	Recipient Address	Monthly Amount	Are You Current?	Amount Past Due
				Yes No Not Sure	$

Step 4 - Attorney Screening

Are you currently involved in a lawsuit?

Yes

Lawsuits

Opposing Party Name	Court	Case Number	Status

Are your wages or bank accounts being garnished?

Yes

Garnishments

Creditor Name	Garnishment Type	Amount Being Taken
		$

Have you participated in any of the following within the last 24 months?

Sports Betting

Online Gambling

Casino Gambling

Day Trading

Cryptocurrency Trading

None of the Above

Approximate amount spent during the last 12 months

Are you still participating?

Yes

Not Applicable

Are you expecting money from any source?

Yes

Money Owed To You / Expected Money

Type	Expected Amount	Expected Date	Description
	$

Have you received any single deposit or transfer over $1,000 within the last 12 months?

Yes

Large Deposits / Transfers

Date	Amount	Source	Description
	$

Step 5 - Real Estate

Do you own or have any interest in real estate?

Yes

Real Estate Properties

Property Address	County	State	Property Type	Do you live at this property?	Is anyone else on the deed/title?	Co-Owner Name(s)	Estimated Fair Market Value	Mortgage Balance	Monthly Mortgage Payment	Are you behind on payments?	Approximate Arrears	Do you want to keep this property?
				Yes No Part-Time	Yes No		$	$	$	Yes No	$

Have you sold, transferred, or given away any real estate in the last 4 years?

Yes

Real Estate Transfers

Property Address	Date Transferred	Who received it?	Sale/Transfer Amount
			$

Step 6 - Vehicles

Do you own, lease, finance, or regularly use any vehicles?

Yes

Vehicles

Year	Make	Model	Trim	VIN	Mileage	Ownership Type	Condition	Estimated Value	Lender Name	Monthly Payment	Approximate Balance Owed	Who owns this vehicle?	Vehicle Usage	Keep or Surrender?
								$		$	$

Have you sold, traded, transferred, repossessed, or surrendered a vehicle within the last 4 years?

Yes

Vehicle Transfers

Year / Make / Model	Date Transferred	Type	Amount Received	Recipient / Buyer
			$

Do you have any pending insurance claims or accident claims involving a vehicle?

Yes

Claim Details

Step 7 - Personal Property

Household Goods Estimated Garage-Sale Value

Electronics Estimated Garage-Sale Value

Clothing Estimated Garage-Sale Value

Do you own jewelry with resale value?

Yes

Jewelry

Description	Estimated Value
	$

Do you own collectibles, antiques, coins, sports cards, or memorabilia?

Yes

Collectibles

Description	Estimated Value
	$

Do you own business tools, equipment, inventory, or supplies?

Yes

Business Equipment

Description	Estimated Value
	$

Do you have a safe deposit box?

Yes

Safe Deposit Box Institution

Brief description of contents

Do you have a storage unit?

Yes

Storage Unit Institution

Storage Unit Street Address

Storage Unit City

Storage Unit Zip

Storage Unit Number

Storage Unit State

Brief description of contents

Step 8 - Financial Accounts

Cash on Hand

Do you have any bank, credit union, online banking, or money app accounts?

Yes

Financial Accounts

Account Type	Institution Name	Last 4 Digits of Account Number	Current Balance	Account Owner	Is this account currently open?
			$		Yes No

Have you closed any financial accounts within the last 12 months?

Yes

Closed Accounts

Institution Name	Account Type	Last 4 Digits	Date Closed	Balance at Closing
				$

Do you have retirement or pension accounts?

Yes

Retirement Accounts

Type	Institution	Last 4 Digits	Current Balance	Loans Against Account?	Approximate Loan Balance
			$	Yes No	$

Do you own any life insurance policies with cash value?

Yes

Not Sure

Life Insurance Policies

Company Name	Policy Type	Cash Value	Death Benefit
		$	$

Step 9 - Income

Do you currently receive income from any source?

Yes

Income Sources

Who receives this income?	Income Type	Source Name	Gross Monthly Amount	How Often Paid?	Is this income expected to continue?	Occupation (if employment)	Employer City and State (if employment)	Years at Employment/Business	Additional Months
			$		Yes No Not Sure

Does anyone who is not filing contribute to household expenses?

Yes

Household Contributions

Contributor Name	Relationship	Monthly Contribution
		$

Step 10 - Monthly Expenses

Mortgage or Rent

Homeowners/Renters Insurance

Property Taxes

HOA / Condo Fees

Home Repair & Maintenance

Electric

Natural Gas

Water / Sewer / Trash

Landline / Internet / Cable

Cell Phone

Streaming Services

Lawn Service

Pool Service

Home Security

Pest Control

Groceries / Household Supplies / Eating Out

Personal Care Products

Haircuts

Cleaning & Laundry

Clothing

Recreation

Gym Membership

Medical Expenses

Medical Prescriptions

Dental Expenses

Vision Expenses

Health Insurance

Life Insurance

401(k) Contributions

Tax Payments

Auto Insurance

Fuel

Vehicle Maintenance

Daycare / Babysitting

Children Education Expenses

Child Support / Alimony Paid

Charity

Student Loan Payment

Result

Are you behind on your mortgage or rent?

Yes

Approximate Amount Behind

Are you behind on vehicle payments?

Yes

Which vehicle(s) and approximate amount behind?

Have you used payday loans, cash advances, or title loans in the last 12 months?

Yes

Other Monthly Expenses

Description	Monthly Amount
	$

Step 11 - Review & Certification

Certification

I certify that the information provided is true and correct to the best of my knowledge.

Electronic Signature - Type Your Full Name

Date

Submission of this questionnaire does not mean your case is ready to file. Our office will review your responses and contact you regarding any additional information or documents needed.

Dropdown

Call Us Today!

Bankruptcy Intake Questionnaire

Step 1 - Contact & Filing Information

Step 2 - Residence & Household

Step 3 - Bankruptcy Background

Step 4 - Attorney Screening

Step 5 - Real Estate

Step 6 - Vehicles

Step 7 - Personal Property

Step 8 - Financial Accounts

Step 9 - Income

Step 10 - Monthly Expenses

Step 11 - Review & Certification

Call Us Today!

Get A Free
Case Evaluation Now!

Bankruptcy Intake Form

Bankruptcy Intake Questionnaire

Step 1 - Contact & Filing Information

Step 2 - Residence & Household

Step 3 - Bankruptcy Background

Step 4 - Attorney Screening

Step 5 - Real Estate

Step 6 - Vehicles

Step 7 - Personal Property

Step 8 - Financial Accounts

Step 9 - Income

Step 10 - Monthly Expenses

Step 11 - Review & Certification

Call Us Today!

Text Us!

Get A Free Case Evaluation Now!

Get A Free
Case Evaluation Now!