Bankruptcy Intake Form Bankruptcy Intake Form Date Name Address City Zip Address Cell phone number Other phone number Email Referred by Is 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 date Purchase price Monthly payment Monthly payment Other real estateYesNoIf 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?YesNoIf yes, explain: Expensive household furnishing, especially recent purchases: Expensive clothing?YesNoValue Jewlery value Collectibles/antiquesYesNoValue Collectibles owed to you:YesNoAmount Bank accounts-checking amount Savings amount Taxes owed Tax returns filed for last 2 years?YesNoRefund last year?YesNoWhen? Total amount Party to any lawsuitsYesNoAttachments-garnishmentsYesNoAmount Transfers of real or personal propertyYesNoPrior bankruptciesYesNoIf yes, when Cash value of life insurance policies Retirement IRA, Keogh: amount Receive workers' compensation benefitsYesNoHow long have you lived in Maryland? Employer Income last year Child support arrearageYesNoAmount Student loansYesNoAmount
