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:
Garnishment
Repossession
Foreclosure
Other
Deadline Date:
Creditor Name and Contact Info:
Assistance Needed:
Bankruptcy
Loan Mod
Debt Negotiation
Tax Resolution
Foreclosure Defense
Are you married?
Yes
No
Is Spouse intending to File?
Yes
No
# 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:
Yes
No
Have you lived in the state for the last 2 years?
Yes
No
Do you receive any money from an annuity or trust?
Yes
No
Do you have anything in your possession that belongs to someone else?
Yes
No
Does anyone have possession of anything that belongs to you?
Yes
No
Do you have any property titled in your name that really belongs to someone else?
Yes
No
Have you sold or transferred any property in the last 48 months?
Yes
No
Have you made any large purchases in the last 90 days?
Yes
No
Have you paid back friends or relatives more than $300 in the past 12 months?
Yes
No
Has any creditor ever taken back, repossessed, or foreclosed on your home or car?
Yes
No
Have you taken out any loans or cash advances in the last 90 days?
Yes
No
Do estranged or ex-spouses have any claims against you?
Yes
No
Do you owe any overdue child support or alimony? If so, how much? $
Yes
No
Are you separated from your spouse or contemplating separation?
Yes
No
Are you required to pay any child support or alimony?
Yes
No
Did you transfer any property to your ex-spouse?
Yes
No
Have you had any car accidents in the last 4 years that were your fault?
Yes
No
Are any of your debts being paid by payroll deductions or military allotment?
Yes
No
Are you repaying any 401k loans or other loans against your retirement?
Yes
No
Have you listed any motor vehicles as collateral for a personal loan?
Yes
No
Have you co-signed a loan or credit card for anyone?
Yes
No
Do you have any co-signors on any of your loans?
Yes
No
Has anyone served you with court papers or filed a lawsuit against you in the past 3 years?
Yes
No
Does anyone have a judgment against you?
Yes
No
Have you owned a business within the past 6 years?
Yes
No
Are you currently operating a business?
Yes
No
Are there any tax returns that you haven’t filed? If so, what years? 2017 / 2016 / 2015 / other
Yes
No
Do you owe any real estate or personal property taxes?
Yes
No
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
--Select--
1 Week
2 Weeks
3 Months
1 Month
2 Month
6 Month
1 Year
2 Year
3 Year
4 Year
5 Year
)
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?
Yes
No
Name on Title:
Property Address:
Non-Mortgage Liens?
Yes
No
Do you want to?
Move
Stay
Est. Value: $
1st Mortgage Lender:
Loan Bal: $
Monthly Payment: $
Rate:
%
Months Behind:
Have you ever modified the loan?
Yes
No
Do you wish to modify the current loan
Yes
No
Reviewed During Consultation
Reaffirm the debt?
Yes
No
Other?
2nd Mortgage Lender:
Loan Bal: $
Monthly Payment: $
Rate:
%
Months Behind:
Have you ever modified the loan?
Yes
No
Do you wish to modify the current loan
Yes
No
Reviewed During Consultation
Reaffirm the debt?
Yes
No
Strip the lien?
Yes
No
Other?
Rental Housing:
Rental
Months Behind:
Do you want to?
Move
Stay
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?
Yes
No
Financed?
Yes
No
Leased?
Yes
No
Lender:
Balance: $
Monthly Payment: $
Rate:
%
Months Behind:
Repossessed?
Yes
No
Repossessed Date:
Want to Recover?
Yes
No
Reviewed During Consultation
Surrender?
Yes
No
Reaffirm?
Yes
No
Retain and Pay?
Yes
No
Cram Down?
Yes
No
Priority Debts
Federal Taxes (IRS)
Amount Owed:
$
2016 Refund Received:
$
2017 Refund Expected:
$
Tax Years Not Filed:
Last Year Filed:
Tax Lien:
Yes
No
Unknown
State Taxes
Amount Owed:
$
2016 Refund Received:
$
2017 Refund Expected:
$
Tax Years Not Filed:
Last Year Filed:
Tax Lien:
Yes
No
Unknown
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:
Yes
No
(Non-Dischargeable)
Unpaid Tuition:
Yes
No
(May be discharged)
Paid:
Outside Plan
Defer?
Amount Owed:
$
Paid to:
Monthly Payment:
$
CoDebtor:
Other Unsecured Debts
Credit Card Debt:
Yes
No
Amount Owed:
Medical Debt:
Yes
No
Amount Owed:
Payday Loans:
Yes
No
Amount Owed:
Other Loans:
Yes
No
Amount Owed:
Other Repossessions (within the last 12 months)
1. Description:
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
FOR OFFICE USE ONLY
Other Concerns
FDCPA Violations
YES
NO
Personal Injury
YES
NO
Estate Planning
YES
NO
Family Law
YES
NO
Social Security Disability/Workers Compensation
YES
NO
Course of Action:
Ch 7:
Ch 13:
Ch 11:
LM:
SS:
DN:
TN:
Other:
Attorney Initials
Case Manager:
Quoted Fees:
Attorney Fees:
Filing Fee:
Credit Report:
NOTES
Notes