Bankruptcy Intake Form - Altamonte, FL

Bankruptcy Client Intake Form

Please complete each section as accurately as possible. This form does not collect full Social Security numbers. You will be sent a different link for all document uploads.

Step 1 - Contact & Filing Information

How Did You Hear About Us?

Debtor Salutation

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 Salutation

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

Unit/Apt #

Current City

Current State

Current ZIP Code

County of Residence

Residence Type

Years 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 (Heads on beds)

Do you have dependents?

Yes

Dependents

Relationship	Age	Lives With You?

Step 3 - Bankruptcy Background

Have you filed bankruptcy within the last 8 years?

Yes

Have you filed all required tax returns for the previous 3 years?

Yes

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

Step 4 - Qualification 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

Are you owed any money?

Yes

Money Owed To You / Expected Money

Type	Expected Amount	Expected Date	Description
	$

Other than your paycheck, have you received any single deposit or transfer over $1,000 within the last 12 months?

Yes

Large Deposits / Transfers

Amount	Source	Description
$

Step 5 - Real Estate

Do you own or have any interest in real estate?

Yes

Real Estate Properties

Property Address	State	Property Type	Is anyone else on the deed/title?	Are you behind on payments?	Approximate Arrears	Do you want to keep this property?
					$

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

Vehicle Type	Year	Make	Model	Mileage	Ownership Type	Lender Name	Monthly Payment	Keep or Surrender?
							$

Have you transferred (sold, traded, surrendered, repossessed, etc.) any vehicles within the last 2 years?

Yes

Vehicle Transfers

Vehicle Type	Year	Make	Model	Date Transferred	Type	Amount Received	Who Received the Transfer?
						$

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

Yes

Claim Details

Step 7 - Personal Property

Household Items

Household Goods Estimated Garage-Sale Value

Electronic Items

Electronics Estimated Garage-Sale Value

Clothing

Clothing Estimated Garage-Sale Value

Jewelry

Jewelry Estimated Pawn Shop Value

Collectibles

Collectibles Estimated Garage-Sale Value

Leisure Goods

Leisure Goods Estimated Garage-Sale Value

Pets

Pets 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 Name

Storage Unit Street Address

Storage Unit City

Storage Unit State

Storage Unit Zip

Brief description of contents

Does anyone other than the Debtor and/or Co-Debtor have access to the storage unit?

Yes

People who have access to the storage unit

Street Address

City

State

Zip

Step 8 - Financial Accounts

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

Yes

Financial Accounts

Account Type	Institution Name	Last 4 Digits of Account Number	Current Balance
			$

Which of these money transfer apps have you used within the last 2 years?

Apple Cash

Cash App

PayPal

Venmo

Other

I have not used any of these apps to transfer or receive money within the last two years.

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

Yes

Closed Accounts

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

Do you have retirement or pension accounts?

Yes

Retirement Accounts

Type	Institution	Last 4 Digits

Do you own any whole, universal or variable life insurance policies with cash value?

Yes

Life Insurance Policies

Company Name	Policy Type	Current Cash Value	Beneficiary
		$

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	Is this income expected to continue?	Job Title (if employment)	Length of Employment/Business
			$

Does your non-filing spouse receive income from any source?

Yes

Income Sources

Income Type	Source Name	Gross Monthly Amount	Is this income expected to continue?	Job Title (if employment)	Length of Employment/Business
		$

Step 10 - Monthly Expenses

Home

Mortgage or Rent

HOA / Condo Fees

Homeowners/Renters Insurance

Property Taxes

Home Repair & Maintenance

Lawn Service

Utilities & Bills

Electric

Natural Gas

Water / Sewer / Trash

Landline / Internet / Cable

Cell Phone

Streaming Services

Pool Service

Home Security

Pest Control

Personal

Groceries / Household Supplies / Eating Out

Personal Care Products

Haircuts

Cleaning & Laundry

Clothing

Recreation

Medical

Medical Expenses

Medical Prescriptions

Dental Expenses

Vision Expenses

Taxes / Insurance

Tax Payments

Life Insurance

Other Insurance

Vehicles

Auto Insurance

Fuel

Vehicle Maintenance

Other Transportation

Car Payment 1

Car Payment 2

Family

Daycare / Babysitting

Children Education Expenses

Child Support / Alimony Paid

Student Loan Payment

Charity

Gym Membership

Result

Do you have any other Monthly Expenses?

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 client intake form does not mean your case is ready to file. Our office will review your responses and contact you regarding any additional information and documents needed.