Bankruptcy Consult Intake

1. Answer all questions to the best of your ability. If a question does not apply
to you answer “N/A”.
YOU MUST COMPLETELY FILL OUT THIS FORM!
2. You must list ALL of your property and ALL of your debts. Do not omit
anything!
3. If your name is on the deed, title, or account you should list it.
4. You must list your property whether you owe on it or not or whether you
want to “include” it or not.
5. Deliberately withholding information can lead to the dismissal of your case.
6. ALL income for the household must be listed! This includes your spouses’
income, even if they are not filing with you and any government benefits
such as unemployment, food stamps, SSI, Disability, and child support.

I have read understand the above instructions. I understand that the information contained in
these forms will be used to prepare my bankruptcy petition. I understand that not following
the above instructions, willfully omitting information or lying about any question will have
serious consequences including possible dismissal of my case and perjury charges.

__________________________ __________________________
Signature Date

__________________________ __________________________
Signature Date
Full Name: ______________________________ Full Name: __________________________
(First Middle Last) (First Middle Last)
Single Married Divorced Single Married Divorced
Separated Widowed Separated Widowed

Maiden/Prior-married names used within last five years: ________________________________

Birth Date: ____________________ Birth Date: _____________________
SSN: ________________________ SSN: _________________________
Street Address:_________________________________________________________
City: ________________ County: ______________ State: AL ZIP: _______
Mailing Address: _____________________________________________________
City: ________________ County: ______________ State: AL ZIP: _______
Home Phone: ( ) - Home Phone: ( ) -
Work Phone: ( ) - Work Phone: ( ) -
Cell Phone: ( ) - Cell Phone: ( ) -
E-mail: _____________________ E-mail: _________________________
Has Client1 ever filed bankruptcy before? Y N
If so, when? _________________________
If so, where? _______________________ Case No.? ________________
Has Client2 ever filed bankruptcy before? Y N
If so, when? _________________________
If so, where? _______________________ Case No.? ________________

RESIDENCE
Do you rent own other:_________________________________
Description of any real property (i.e., land, house, mobile home) you own or are buying:
______________________________________________________________________
Date acquired_____/_____/_____ Balance owed: $_________________
Name of mortgage company (if any): _______________________________________
Are you behind? Yes No If yes, how much?____________________________
Co-debtor(s) name & address: _______________________________________________________
Do you want to keep this subject to any balance? Y N
Name of 2nd mortgage company (if any): ______________________________________________
Balance owed: $_________________

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AUTOMOBILE #1: Make: _______________ Model: __________________ Color:____________
Year: _______________ Miles: ______________ Date acquired ___/___/_____
Co-debtor(s) name & address: ________________________________________________________
Names on Title: ___________________________________________________________________
Name of financing company (if any): ___________________________________________________
Is this a title loan or a pawn? Yes No Are you behind? Yes No
If yes, how much?________________ Balance owed: $_________________
Do you want to keep this subject to any balance? Y N

AUTOMOBILE #2: Make: _______________ Model: __________________ Color:____________

Year: _______________ Miles: ______________ Date acquired ___/___/_____
Co-debtor(s) name & address: ________________________________________________________
Names on Title: ___________________________________________________________________
Name of financing company (if any): ___________________________________________________
Is this a title loan or a pawn? Yes No Are you behind? Yes No
If yes, how much?________________ Balance owed: $_________________
Do you want to keep this subject to any balance? Y N

OTHER VEHICLE #1: (jet ski, 4 wheeler ect) ________________________________________________________

Co-debtor(s) name & address: ________________________________________________________
Names on Title: ___________________________________________________________________
Name of financing company (if any): ___________________________________________________
Is this a title loan or a pawn? Yes No Are you behind? Yes No
If yes, how much?________________ Balance owed: $_________________
Date acquired ___/___/_____ Do you want to keep this subject to any balance? Y N

OTHER VEHICLE #2: (jet ski, 4 wheeler ect) ________________________________________________________

Co-debtor(s) name & address: ________________________________________________________
Names on Title: ___________________________________________________________________
Name of financing company (if any): ___________________________________________________
Is this a title loan or a pawn? Yes No Are you behind? Yes No
If yes, how much?________________ Balance owed: $_________________
Date acquired ___/___/_____ Do you want to keep this subject to any balance? Y N

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FINANCIAL ACCOUNTS:
ACCOUNT #1: Name of Financial Institution: _______________________________________
Type of Account (checking, savings, retirement): ____________________
Names on Account: _______________________________________________
Current Account Balance: $________

ACCOUNT #2: Name of Financial Institution: _______________________________________

Type of Account (checking, savings, retirement): ____________________
Names on Account: _______________________________________________
Current Account Balance: $________

ACCOUNT #3: Name of Financial Institution: _______________________________________

Type of Account (checking, savings, retirement): ____________________
Names on Account: _______________________________________________
Current Account Balance: $__________

OTHER ASSETS:
Do you own a time-share condo? Y N If so, location: ___________________
If so, give name and address of company from whom you purchased it:
____________________________________________________________________________
Date acquired_____/_____/__________

Do you have a retirement account? Y N

If so, describe each: ____________________________________________________________

Do you own any stocks or bonds? Y N

If so, describe each:
Company # of Shares Date Bought Current $ Value
___________________ ________ _________ ____________
___________________ ________ _________ ____________
___________________ ________ _________ ____________

Do you have a safety deposit box or storage building? Y N

If so, describe each and what is contained in each: _____________________________
______________________________________________________________________
______________________________________________________________________

LIABILITIES:
Please list by creditor name and approximate date loans taken out or credit cards used in the last 90 days:

Name:________________________________ Amount $ ________ Date: _________

What did you use the money for?______________________________________________________

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Name:________________________________ Amount $ ________ Date: _________
What did you use the money for?______________________________________________________

Name:________________________________ Amount $ ________ Date: _________

What did you use the money for?______________________________________________________

Name:________________________________ Amount $ ________ Date: _________

What did you use the money for?______________________________________________________

Name:________________________________ Amount $ ________ Date: _________

What did you use the money for?______________________________________________________

Did you pay more than $600.00 or more to any 1 creditor in the last ninety (90) days?

Name:________________________________ Amount $ ________ Date: _________

Where did you get the money to you used to pay this?____________________________________

Name:________________________________ Amount $ ________ Date: _________

Where did you get the money to you used to pay this?____________________________________

Have you applied for a loan that required a financial statement in the last year? Y N
With what company? ____________________________________________________

Do you have loans that you put collateral up with? (TV, lawn mower, ect) Y N
Name:________________________________ Amount $ ________ Date: _________
What did you put up?_______________________________________________________________

Name:________________________________ Amount $ ________ Date: _________

What did you put up?_______________________________________________________________
Name:________________________________ Amount $ ________ Date: _________
What did you put up?_______________________________________________________________

Name:________________________________ Amount $ ________ Date: _________

What did you put up?_______________________________________________________________

Name:________________________________ Amount $ ________ Date: _________

What did you put up?_______________________________________________________________

How much do you estimate that you owe in total on unsecured loans? $_____________
How much do you estimate you owe in total on credit cards? $_____________
How much do you estimate you owe in total for medical bills? $_____________

5
EMPLOYMENT INFORMATION

Client1 Client2

Occupation

Name of Employer

Address of Employer

How Long with Employer

How often are you paid?

OTHER INCOME
Monthly income from alimony: $__________________________
Monthly income from child support: $__________________________
Monthly income from Social Security $__________________________
Monthly income from Veterans Admin $__________________________
Monthly income from TANF or other DHS: $__________________________
Other Monthly income besides work or above $__________________________

DEPENDENTS:
Name: Age: Lives w/ you? Pay/Receive Child Support
________________________ ____ _______________ _____________________
________________________ ____ _______________ _____________________
________________________ ____ _______________ _____________________
________________________ ____ _______________ _____________________
________________________ ____ _______________ _____________________

Do you owe child support to anyone? Y N

If yes, who?____________________________________________________________

Does anyone owe you child support? Y N

If yes, who?____________________________________________________________

Have you transferred any property to anyone in the last 2 years? Y N

If yes:
What was the property?_____________________________________________________
Did you give it away or sell it?________________________________________________
Who did you transfer it to?___________________________________________________

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MONTHLY EXPENSES:

Rent or Mortgage Payment

Electric, gas, and propane (all that apply, combined)

Water and sewer

Residential Telephone

Cellular Telephone

Cable TV or Satellite TV

Other Utility (if any, describe here):

Home Maintenance, Repair and/or Upkeep

Food (groceries and eating out)

Clothing, Shoes and Accessories

Laundry-mat and/or Dry Cleaning

Uninsured prescriptions or medical expenses

Transportation (gasoline and/or taxi/bus fares)

Recreation, clubs, and other entertainment

Charitable Contributions or Church Tithe

Homeowner/Renter Insurance

Life Insurance

Health Insurance

Auto Insurance

Other Insurance (if any, describe here):

Taxes (if any, describe here):

Auto Installment Payments

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Other Installment Payments (if any, describe here):

Alimony and/or Child Support Payments

Other Payments to Dependents not living in home

Child Care Expenses

Student Loan Payments

Other Payments (if any, describe here)

Did you file taxes in? ____ 2016 _____2017 _____2018 If not, why? ____________________

REPOSSESSIONS OR FORECLOSURES WITHIN THE LAST 2 YRS

What/Value When Creditor

PEOPLE YOU SUED OR WHO SUED YOU WITHIN THE LAST 1 YR

Case Name Case Number Court Name Description

HAVE YOU CLOSED ANY ACCOUNTS WITHIN THE LAST 1 YR?

Name and Address of Date Reason Balance

Financial Institution Closed Closed When Closed

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PRIOR ADDRESSES WITHIN THE LAST 2 YRS

Address Names of Residents Beginning Date Ending

of Residency Date of
Residency

Have you given away anything to anyone worth more than $600 in the last 2 years? Y N
If yes: What did you give away and who did you give it to?
________________________________________________________________________________
________________________________________________________________________________

Have you lost anything to disaster, fire, theft or gambling within the last year? Y N
If yes, what did you lose and how:
________________________________________________________________________________
________________________________________________________________________________
________________________________________________________________________________

Did you file an insurance claim? Y N If yes, what Ins. Company: _________________

Did you get reimbursed? Y N If yes, how much? $ ___________

Did you file a Police Report? Y N Jurisdiction: ________________________

NOTES:
________________________________________________________________________________
________________________________________________________________________________
________________________________________________________________________________
________________________________________________________________________________

I declare that the information provided is correct to the best of my knowledge. I understand that the
information contained in these forms will be used to prepare my bankruptcy petition. I understand that
willfully omitting information or lying about any question will have serious consequences including but
not limited to possible dismissal of my case and perjury charges.

____________________________________________ _____/_____/_____
Signature of Debtor Date

____________________________________________ _____/_____/_____
Signature of Co-Debtor Date