Bankruptcy Intake Form "*" indicates required fields Today's Date Month Day Year Personal Information for Client #1Full Name* First Name Middle Name Last Name Suffix PhoneEmail Address STREET CITY STATE ZIP Occupation Age Number of dependent children of any age12345678910Have you lived in Michigan for the last two years? Yes No If no, what city and state did you live? Information about spouse, if married (Client #2)Full Name First Name Middle Name Last Name Suffix PhoneEmail Address STREET CITY STATE ZIP Occupation Age Number of dependent children of any age12345678910Have you lived in Michigan for the last two years? Yes No If no, what city and state did you live? Marital StatusMarital StatusNever MarriedMarried, Living TogetherMarried, Living ApartDomestic PartnerDivorcedWidowedDivorced Date Month Day Year How did you first hear about us?GoogleYahooBingAvvoReferralOtherPlease describe Assets (Real Estate, Vehicles, Boats, etc.)Home/Residence STREET CITY STATE ZIP Home ValueMortgage Balance - 1st MortgageMonthly Payments - 1st MortgageMonthly Payments - 2nd MortgageMortgage Balance - 2nd MortgageAre the 1st mortgage payments current? Yes No Are the 2nd mortgage payments current? Yes No Add More Real Estate? Yes No Real Estate Address #2 STREET CITY STATE ZIP Mortgage Balance - 1st MortgageMonthly Payments - 1st MortgageMortgage Balance - 2nd MortgageMortgage Payments - 2nd MortgageAre the 1st mortgage payments current? Yes No Are the 2nd mortgage payments current? Yes No Real Estate Address #3 STREET CITY STATE ZIP Mortgage Balance - 1st MortgageMortgage Payments - 1st MortgageMortgage Balance - 2nd MortgageMortgage Balance - 2nd MortgageAre the 1st mortgage payments current? Yes No Are the 2nd mortgage payments current? Yes No Do you rent? Yes No If yes, what is your monthly rental income?Vehicle #1 (Make/Model/Year Vehicle #1 ValueVehicle #1 Loan BalanceVehicle #1 Monthly PaymentsAre the payments current for Vehicle #1? Yes No Vehicle #2 (Make/Model/Year Vehicle #2 ValueVehicle #2 Loan BalanceVehicle #2 Monthly PaymentsAre the payments current for Vehicle #2? Yes No Vehicle #3 (Make/Model/Year Vehicle #3 ValueVehicle #3 Loan BalanceVehicle #3 Monthly PaymentsAre the payments current for Vehicle #3? Yes No JudgementsUse + sign to add additional linesCreditorAmount of JudgementDate of EntryNature of Debt Add RemoveUnsecured DebtsCREDIT CARDSNumber of Accounts/Cards Total OwedAre your payments current? PERSONAL LOANSNumber of Accounts/Cards Total OwedAre your payments current? MEDICAL DEBTSNumber of Accounts/Cards Total OwedAre your payments current? STUDENT LOANSNumber of Accounts/Cards Total OwedAre your payments current? TAX DEBTSNumber of Accounts/Cards Total OwedAre your payments current? OTHER DEBTSNumber of Accounts/Cards Total OwedAre your payments current? IncomeCLIENT #1 - LIST GROSS PRE-TAX INCOME (ex: employment, business, disability, rent, social security, VA benefits, gifts, or any other income REGARDLESS of whether it is taxable). Use + to add more lines. ListSourceAnnual Income Add RemoveDo you expect any change in income? Yes No If yes, please explain CLIENT #2 (SPOUSE, IF MARRIED) - LIST GROSS PRE-TAX INCOME (ex: employment, business, disability, rent, social security, VA benefits, gifts, or any other income REGARDLESS of whether it is taxable). Use + to add more lines. ListSourceAnnual Income Add RemoveDo you expect any change in income? Yes No If yes, please explain Other AssetsDo you have an ownership interest in any other assets worth more than $5,000, other than retirement accounts? Yes No Notes/CommentsPlease explain anything here that you believe may be relevant to your case.Name First Last Address STREET COUNTY CITY STATE ZIP Home PhoneCell PhoneWork PhoneEmail How Did You Hear About Us?PLEASE SELECT ONEALLEGAN COUNTY LEGAL ASSISITANCE CENTERFACEBOOKALLEGAN NEWSONLINE SEARCHREFERRED BYOTHERPlease Explain Type of CasePLEASE SELECT ONECRIMINALFAMILY LAWWILLS/TRUSTSLITIGATIONBANKRUPTCYSOCIAL SECURITYOTHERPlease Explain CAPTCHAEmailThis field is for validation purposes and should be left unchanged.
