Bankruptcy Intake Form

Date
Name
Address
City
Zip
Address
Cell phone number
Other phone number
Email
Referred by
Is he/she an attorney?
Are you a veteran, member of armed services or a registered nurse?
If yes, which one?
How many people are in your household?
How many dependents?
Is your spouse filing?
Real estate: In whose name(s)
Purchase date
Purchase price
Monthly payment
Monthly payment
Other real estate
If yes, explain:
Motor vehicles (how many?)
Vehicle #1-In whose name(s)
Year
Make
Model
Body style
Mileage
Amount owed
Monthly payment
Vehicle #2-In whose name(s)
Year
Make
Model
Body style
Mileage
Amount owed
Monthly payment
Other vehicles?
If yes, explain:
Expensive household furnishing, especially recent purchases:
Expensive clothing?
Value
Jewlery value
Collectibles/antiques
Value
Collectibles owed to you:
Amount
Bank accounts-checking amount
Savings amount
Taxes owed
Tax returns filed for last 2 years?
Refund last year?
When?
Total amount
Party to any lawsuits
Attachments-garnishments
Amount
Transfers of real or personal property
Prior bankruptcies
If yes, when
Cash value of life insurance policies
Retirement IRA, Keogh: amount
Receive workers' compensation benefits
How long have you lived in Maryland?
Employer
Income last year
Child support arrearage
Amount
Student loans
Amount