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Bankruptcy Intake Form

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Details

Name:

Please enter your name.

Address:

Please enter your street address.

City:

Please enter the name of your city.

State:

Please choose your state of residence.

ZIP Code:

Please enter a valid ZIP code. You may use 0-9, spaces and the ( ) – + characters.

Email Address:

Please enter a valid email address.

Home Phone:

Please enter a valid home phone number. You may use 0-9, spaces and the ( ) – + characters.

Business Phone:

Mobile Phone:

Fax Number:

Do you intend to file a joint bankruptcy petition?

Yes No

If yes, include information for both yourself and your spouse below.

Name(s), including middle initial:

Residence address, including county:

How long have you been at this address?

Other Address:	How Long?

Other telephone number(s):

Work:

Cell:

Other:

Have you used any other name(s) in the last six years?

Yes No

If yes, please list here:

Single Separated Married Divorced

If married, how long?

If divorced, how long?

Ages of minor children living with you:

Ages, and amount of child support paid:

Age	Amount
	$
	$
	$
	$

Is any child support past due?

Yes No

Amount:

$

Husband’s employment:

How long at this job?

Occupation:

Income paid:

weekly semi-monthly monthly other

Gross:

Net:

Wife’s employment (name and addr.):

How long at this job?

Occupation:

Income paid:

weekly semi-monthly monthly other

Gross:

Net:

Income from other sources (second job, investments, social security, child support, worker’s compensation, etc. (state source and amount):

Do you owe any money to the Internal Revenue Service?

Yes No

If yes, for what year(s)?

How much?

$

Do you have any unpaid student loans?

Yes No

Amount:

$

Monthly Expenses:

Rent	Real Estate Taxes
Electric	Home Maintenance
Gas	Life Insurance
Water	Health Insurance
Phone	Auto Insurance
Cable	Homeowner/Rent Ins.
Trash	House Payment

Do you pay anyone spousal support (alimony)?

Yes No

If yes, to whom and how much?

Do you own or are you purchasing a home or other real property?

Yes No

Tax assessed value:

$

First mortgage loan balance:

$

Loan current?

Amount behind:

$

2nd mortgage loan balance:

$

Loan current?

Amount behind:

$

3nd mortgage loan balance:

$

Loan current?

Amount behind:

$

Are you facing foreclosure?

Yes No

Foreclosure date:

List any liens against your property:

List all vehicle loans (car, truck, motorcycles; identify vehicle type):

Vehicle:
Est. Loan Balance:	$
Loan Current:
Amount Behind	$
Vehicle:
Est. Loan Balance:	$
Loan Current:
Amount Behind	$
Vehicle:
Est. Loan Balance:	$
Loan Current:
Amount Behind	$

List all vehicles you own outright (no loan balance):

Vehicle	Est. Value
	$
	$

Have you purchased any secured items (electronics, boats, jet ski, appliances, etc.) in the last two years on which you still owe money?

Yes No

Have you taken out a loan from a finance company, credit union, bank or any other place and secured the loan by household items or other type of secured collateral?

Yes No

Creditors’ names:

Estimate balances owed on all other types of debt listed below:

$ Medical Bills

$ NSF Checks

$ Credit Cards

$ Misc. Bills

When was the last time you used any of your credit cards? (approx. date)

How much has total owed on cards gone up in the last 12 months?

Do you anticipate receiving a tax refund?

How much?

$

Are you eligible for the Earned Income Credit?

Yes No

How much?

$

List all judgements, lawsuits, liens and garnishments against you:

Special concerns:

Where did you hear about this website?

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James O.Cure

Board certified in Consumer Bankruptcy Law and Civil Trial Law by the Texas Board of Legal Specialization.

Bankruptcy

Probate

John R. Francis

Board certified in Personal Injury Trial Law and Civil Trial Law by the Texas Board of Legal Specialization.

Personal Injury

Business & Commercial Litigation