Client Information Form


This Client Information Form is provided in anticipation of your obtaining legal advice. All information is strictly confidential, so please answer truthfully and completely. We can only advise you based on the information you provide to us.

Personal Information

Appointment Date:
How did you hear about us?
Facing:
Deadline Date:
Creditor Name and Contact Info:
Assistance Needed:

Are you married?
Is Spouse intending to File?
# of Dependants:
You Spouse
Full Name (First Middle Last)
Full Name (First Middle Last)
Date of Birth Date of Birth
Phone
Mobile:
Home:
Work:
Phone
Mobile:
Home:
Work:
Email Email
Physical Address
Address:
City:
State:
Zip:
County:
Physical Address
Address:
City:
State:
Zip:
County:
Mailing Address
Address:
City:
State:
Zip:
County:
Mailing Address
Address:
City:
State:
Zip:
County:

Important Questions

Have you ever filed bankruptcy before? If yes,
Filer Name:
State Where Filed:
Date Filed:
Have you lived in the state for the last 2 years?
Do you receive any money from an annuity or trust?
Do you have anything in your possession that belongs to someone else?
Does anyone have possession of anything that belongs to you?
Do you have any property titled in your name that really belongs to someone else?
Have you sold or transferred any property in the last 48 months?
Have you made any large purchases in the last 90 days?
Have you paid back friends or relatives more than $300 in the past 12 months?
Has any creditor ever taken back, repossessed, or foreclosed on your home or car?
Have you taken out any loans or cash advances in the last 90 days?
Do estranged or ex-spouses have any claims against you?
Do you owe any overdue child support or alimony? If so, how much? $
Are you separated from your spouse or contemplating separation?
Are you required to pay any child support or alimony?
Did you transfer any property to your ex-spouse?
Have you had any car accidents in the last 4 years that were your fault?
Are any of your debts being paid by payroll deductions or military allotment?
Are you repaying any 401k loans or other loans against your retirement?
Have you listed any motor vehicles as collateral for a personal loan?
Have you co-signed a loan or credit card for anyone?
Do you have any co-signors on any of your loans?
Has anyone served you with court papers or filed a lawsuit against you in the past 3 years?
Does anyone have a judgment against you?
Have you owned a business within the past 6 years?
Are you currently operating a business?
Are there any tax returns that you haven’t filed? If so, what years? 2015 / 2014 / 2013 / other
Do you owe any real estate or personal property taxes?

Employment and Income


Complete only the rows that apply
You
Spouse
Other Adult in Household
Other Adult in Household
Primary Employer Name
Gross Pay
$  
$  
$  
$  
Net Pay
$  
$  
$  
$  
(Paid Every )
Domestic Support Income
$  
$  
$  
$  
Child Support Income
$  
$  
$  
$  
Social Security
$  
$  
$  
$  
Unemployment
$  
$  
$  
$  
Pension & Retirement Income
$  
$  
$  
$  
Public Benefits
$  
$  
$  
$  
Rental Income
$  
$  
$  
$  
Business Income
$  
$  
$  
$  
Investment Income
$  
$  
$  
$  
Other Income ( )
$  
$  
$  
$  
Total Gross Monthly Income
$  
$  
$  
$  
Are you expecting a change in income or expenses in the future? If yes explain
Was your prior 6 months’ income substantially similar? If no explain

Assets


List your assets and approximate value
Asset Value$ Asset Value$
Cash on Hand Ownership in Business
Checking Tools of the Trade & Business Equipment
Savings Other Business Assets (Inventory, A/R, etc)
Certificates of Deposit Car Leases
Stocks, Bonds, Mutual Funds, & Annuities Valuable Collections
Interest in Insurance Policies (Cash Value or Refund) Personal Injury Claims (car accident, work comp, etc.)
Loans or Mortgages Paid to You Security Deposits Held by Others
Rents Paid to You Furs and Jewelry
Tax Refunds Due to You Animals (pedigree, other than house pets)
Other Amounts Due You (back alimony, loans from friends or relatives, etc.) IRA or 401(k) or Profit Sharing Plans
Other:

Real Estate


Complete this section only if you own real estate. Include your residence, investment property, land, timeshares and other real estate.
Property

Primary Residence?
Name on Title:

Property Address:

Non-Mortgage Liens?
Do you want to?
Est. Value: $

1st Mortgage Lender:

Loan Bal: $ Monthly Payment: $ Rate: % Months Behind:

Have you ever modified the loan?
Do you wish to modify the current loan

2nd Mortgage Lender:

Loan Bal: $ Monthly Payment: $ Rate: % Months Behind:

Have you ever modified the loan?
Do you wish to modify the current loan

Rental Housing:


Rental

Months Behind:
Do you want to?
Monthly Rent: $

Vehicles:


Complete this section for any owned or financed vehicles you possess (or possessed during the last 90 days).
Vehicle

Year:
Make:
Model:
Miles:

Value:
Purchase Date:
Features:

Registration?
Financed?
Leased?
Lender:

Balance: $
Monthly Payment: $ Rate: %
Months Behind:

Repossessed?
Repossessed Date:
Want to Recover?

Priority Debts


Federal Taxes (IRS)
Amount Owed:
$
2014 Refund Received:
$
2015 Refund Expected:
$
Tax Years Not Filed:
Last Year Filed:
Tax Lien:

State Taxes
Amount Owed:
$
2014 Refund Received:
$
2015 Refund Expected:
$
Tax Years Not Filed:
Last Year Filed:
Tax Lien:

Domestic Support Obligation
Amount Owed:
$
Mo. Payment:
$
Term in Months:
Recipient:
Paid To:

Court Fines and Fees
Amount Owed:
$
Mo. Payment:
$
Term in Months:
Recipient:
Paid To:

Restitution/Fines/Misdeanors
Amount Owed:
$
Mo. Payment:
$
Term in Months:
Recipient:
Paid To:

Unsecured Educational Debts



Loans: (Non-Dischargeable)
Unpaid Tuition: (May be discharged)
Paid:

Amount Owed: $
Paid to:
Monthly Payment: $
CoDebtor:

Other Unsecured Debts


Credit Card Debt: Amount Owed:
Medical Debt: Amount Owed:
Payday Loans: Amount Owed:
Other Loans: Amount Owed:

Other Repossessions (within the last 12 months)

1. Description:

Other Foreclosures (within the last 12 months)

1. Description:
I acknowledge that the information submitted in this Client Information Form will be the basis for providing me with legal advice and attest that the information provided is true, correct, and complete to the best of my knowledge. I understand that if I fail to disclose any of my assets, liabilities, income, expenses, liens, and other encumbrances the advice given may have a negative impact on me.
Client
Client