Start your Debt Free Journey

Our new online Bankruptcy Intake Questionnaire is the Fastest and Easiest way to provide us with the initial information we need.
This user-friendly form streamlines the process, so we can quickly evaluate your situation and
get to work on your case FAST.

Bankruptcy Intake Questionnaire

First name

Last name

Email

Phone

Mailing Address

Birthday

Month

Day

Year

SS#

filing with a spouse?

Yes

No

Spouse Name

Spouse Birthday

Spouse SS#

List any Dependents:

Have you or your spouse filed a bankruptcy in the last ten years?

Yes

no

List all real estate you own or are paying for: Please bring statement from your mortgage company or, if land is paid for, bring deed.

If you have a mortgage, are your payments current?

Yes

No

have you received a notice that your house is going to be sold?

Yes

No

List all vehicles that have your name(s) on the title, whether the vehicle is paid for or not. Please bring last statement from your lender or, if paid for, bring title(s).

List all motorcycles, boats, trailers and any other vehicle that is registered in your name(s). Please bring last statement from your lender or, if paid for, bring registration

Do you or your spouse pay Child Support or Alimony?

Yes

No

If Yes, List the Parent/Ex Spouse:

If you don't know the debts or amounts, please continue to finish the form and we will help you with the rest at your appointment.

List all unpaid taxes of any kind.

Do you have any court judgments or liens against you?

Yes

No

If yes, Please provide details & bring court notices: Creditor, Court, Case No.

List all credit cards: Please bring the last statement from your lender(s). Also bring notices from all collection agencies.

List all unpaid loans from cash advance companies:

If you are renting any furniture, appliances, or other items from a rent-to-own company, please list:

Add your text

Income: Please bring paycheck stubs from the last six months. Also bring proof of income from: pension/retirement, SSI, SSDI, child support, alimony, food stamps, self-employment, and all other sources. List Spouse Employment if applicable

I get Paid

Weekly

Bi Weekly

Monthly

Are you involved a lawsuit or settlement that may pay you a settlement or judgment?

Yes

No

If yes, provide details: Court, Case No., Date Filed, Name/Address of Attorney representing you.

Gross Income

List income From real estate: alimony/child support: From SSI/SSDI: food stamp Retirement and other income.

If self-employed please provide proof of income and expenses.

Add a heading

Rent or mortgage payment:

Are real estate taxes included:

Yes

No

Is property insurance included:

Yes

No

List Expenses

List Food: Clothing: Laundry and dry cleaning: Medical & dental expenses: Transportation: Recreation: Charitable contributions and church:

List Insurance: (not deducted from paycheck) Health: Homeowner's or Renter's: Life: Other:

List Car Payments

Are any of your debts listed in your maiden name or any other name?

Yes

No

Are you or your spouse involved in any lawsuits or court proceedings?

Yes

No

Are you expecting any large sums of money within the next year?

Yes

No

Have you transferred real estate or personal property within the last two years?

Option 1

Option 2

Do you have a significant amount of money in any bank account:

Yes

No

Do you own any farm equipment or valuable animals?

Yes

No

Do you owe any past-due alimony or child support?

Yes

No

Are you paying current alimony or child support?

Yes

No

Do any of your debts have a co-signer listed?

Yes

No

Have you used any of your credit cards within the last 90 days?

Yes

No

Have you moved here from another state within the last 2 years?

Yes

No

Do you and your spouse maintain separate households?

Yes

No

Have you created any debt to pay taxes, support or a student loan?

Yes

No

Have any debts been settled through a divorce?

Yes

No

Do you have any unfilled tax returns?

Yes

No

Do you have any debts due to: Drunk driving Criminal restitution Civil restitution Fines Damages from personal actions?

Yes

No

Multi choice

Option 1

Option 2

Do you expect any changes in your income?

Debtor Signature

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Co-Debtor Signature

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Date

Month

Day

Year

Please bring the following documents
to your bankruptcy appointment

Social Security card

Picture ID (example: driver’s license, state identification card)

Your income tax returns for the last two years

Pay stubs for the last six months. (If married, bring spouse’s pay stubs also – whether or not he/she is filing.)

Proof of other income: pension or retirement; government (SSI, Social Security, food stamps, Families First, etc); child or spousal support; self-employment income; from real estate/rental property; all other sources of income

Completed expense schedule (on Questionnaire)

Existing mortgage and automobile debt information

The “Declarations” page of all auto insurance and/or home policies

Statements from all creditors and collection agencies

Documents from any legal actions/lawsuits you are involved in

Statement from all student loan debts

A list of any questions you have

Start your Debt Free Journey

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Please bring the following documents to your bankruptcy appointment

Please bring the following documents
to your bankruptcy appointment