Bankruptcy Intake Form Bankruptcy Intake Form DateNameAddressCityZipAddressCell phone numberOther phone numberEmailReferred byIs he/she an attorney?YesNoAre you a veteran, member of armed services or a registered nurse?YesNoIf yes, which one?How many people are in your household?How many dependents?Is your spouse filing?YesNoReal estate: In whose name(s)Purchase datePurchase priceMonthly paymentMonthly paymentOther real estateYesNoIf yes, explain:Motor vehicles (how many?)Vehicle #1-In whose name(s)YearMakeModelBody styleMileageAmount owedMonthly paymentVehicle #2-In whose name(s)YearMakeModelBody styleMileageAmount owedMonthly paymentOther vehicles?YesNoIf yes, explain:Expensive household furnishing, especially recent purchases:Expensive clothing?YesNoValueJewlery valueCollectibles/antiquesYesNoValueCollectibles owed to you:YesNoAmountBank accounts-checking amountSavings amountTaxes owedTax returns filed for last 2 years?YesNoRefund last year?YesNoWhen?Total amountParty to any lawsuitsYesNoAttachments-garnishmentsYesNoAmountTransfers of real or personal propertyYesNoPrior bankruptciesYesNoIf yes, whenCash value of life insurance policiesRetirement IRA, Keogh: amountReceive workers' compensation benefitsYesNoHow long have you lived in Maryland?EmployerIncome last yearChild support arrearageYesNoAmountStudent loansYesNoAmount