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Intake Form
Intake Form
Please complete this form before your free phone consultation.
Step 1 of 5 - General
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Step 1: Tell us about yourself
Name
First
Last
Address
Street Address
Address Line 2
City
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Armed Forces Americas
Armed Forces Europe
Armed Forces Pacific
State
ZIP Code
Phone
Cell Phone
Email
Marital Status
Married
Single
Divorced
Separated
Spouse's Name (if applicable)
First
Last
Have you lived in CA continuously for the past 2 years?
Yes
No
In which county have you resided for the past 6 months?
Example: Sacramento
Have you or your spouse filed bankruptcy in the past 8 years?
Yes
No
Step 2: Tell us about your debts
Please enter the total amount you owe for each debt category. You don't need to list exact figures. Just tell us how much you owe to the best of your knowledge.
Mortgage(s) / Home Equity Line of Credit
Credit Card
Medical
Personal / Payday Loan
Tax
Student Loan
Child Support / Alimony
Other
Other
Are your debts primarily consumer debts? (not business debts)
Yes
No
Do you owe back child support, alimony or maintenance payments?
Yes
No
Do you have credit card debt due to tax payments?
Yes
No
Do you owe money under a marital settlement agreement?
Yes
No
If you are married, were most of your debts incurred before marriage?
Yes
No
Have you stopped using credit cards?
Yes
No
In the last 90 days have you charged on a single credit card or received a loan for more than $650?
Yes
No
In the last 70 days have you received a cash advance totaling more than $925?
Yes
No
Do you owe any debts that could be considered fraudulent?
Yes
No
Do you owe any court fines or penalties?
Yes
No
Has anyone cosigned for your debt or have you cosigned for another's debt?
Yes
No
Step 3: Tell us about your monthly income
Gross Monthly Income
Income Sources
Ex.) paycheck, social security
Gross Monthly Income (Spouse)
Income Sources (Spouse)
Ex.) paycheck, social security
How many people live in your home?
1
2
3
4
5 or more
Have you filed federal and state tax returns for every year for the past 4 years?
Yes
No
Do you expect an inheritance or money from anyone in the next 5 years?
Yes
No
Monthly Expenses
Please list your monthly expenses for any categories that apply. If a category does not apply enter 0
Mortgage
Car Payment
Car Payment
Child Support / Alimony
Tax Payment / Withholding
Child Care
Step 4: Tell us about your collection history
Are you currently involved in a lawsuit?
Yes
No
Do you have any judgments against you?
Yes
No
Are there any liens on your property?
Yes
No
Are you in danger of being evicted or is your home in danger of foreclosure?
Yes
No
Are your wages being garnished?
Yes
No
Transfers
Have you paid more than $600 to any creditor who is not a friend or relative in the past 90 days?
Yes
No
Have you sold or given any property to a friend or relative you were in debt to in the past year? (365 days)
Yes
No
Have you given any money or transferred any property to a friend or relative in the past 2 years?
Yes
No
Step 5: Tell us about your assets
Real Estate
Do you own real estate?
Yes
No
Are you behind on mortgage payments?
Yes
No
Vehicle #1
Year, Make & Model
Value
Amount Owed
Are you behind on payments?
Yes
No
Did you purchase this vehicle within the past 910 days? (2 1/2 years)
Yes
No
Vehicle #2
Year, Make & Model
Value
Amount Owed
Are you behind on payments?
Yes
No
Did you purchase this vehicle within the past 910 days? (2 1/2 years)
Yes
No
Other Assets
Do you own any personal property in your home that a retailer could resell for more than $650?
Yes
No
Are you expecting a tax refund for any year including this year?
Yes
No
Do you own a recreational vehicle, boat, or ATV?
Yes
No
Even if you never expect to collect, does anyone owe you money?
Yes
No
Do you (or your spouse) have the right to sue anyone for anything?
Yes
No
Do you have retirement funds?
Yes
No
Do you own a business?
Yes
No
Do you have any questions you would like answered during your phone consultation?
Captcha
Name
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Bankruptcy Attorney
Adam Garcia
Bankruptcy Attorney
(916) 500-0704
Mon-Sat
8 AM – 6 PM
Related Pages
Chapter 13 Bankruptcy
Credit Card Fraud
Discharge
Gambling Debt
Student Loans
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