Bankruptcy Chapter 7 Client Information Form

General Contact Information: 

First Name:

Last Name:

Street Address:

City:

State:

Zip:

E-mail Address:

Home Phone:

Work Phone:

Fax Number:

Date Of Birth: 

Marital Status:

Married          Separated       Divorced       Widowed       Single

Employment Info:

Your Present Employer:

Employer's Address:

Employer's Phone Number:

Spouse's Information

Spouse's Name:

DOB:

Spouse's Employer:

Employer's Address:

Employer's Phone Number:

Is this your first experience engaging the service of an attorney?    Yes       No

How were you a referred to this office?

General nature of the issue for which you seek legal advice:

Your Earnings Pay Period:

Weekly      Bi-Weekly       Semi-Monthly       Monthly

Your Spouse's Pay Period:

Weekly      Bi-Weekly       Semi-Monthly       Monthly

BUDGET - INCOME:

Income

Debtor

Spouse

Earnings Per Pay Period:

$

$

Estimated Overtime Per Pay Period:

$

$

Payroll Deductions Per Pay Period:

$

$

Insurance:

$

$

Union Dues:

$

$

Other Deductions:

$

$

Income From Business, Profession:

$

$

Income From Real Property:

$

$

Interest and Dividends:

$

$

Pension and Retirement Income:

$

$

Alimony Received:

$

$

Social Security/Gov't Assistance:

$

$

Other Monthly Income:

$

$

BUDGET - EXPENSES:

Income

Debtor

Spouse

Rent/Mortgage:

$

$

Electricity:

$

$

Water and Sewer:

$

$

Telephone:

$

$

Other Utilities - Cable:

$

$

Other Utilities - Oil/Gas:

$

$

Other Utilities:

$

$

Home Maintenance:

$

$

Food:

$

$

Clothing:

$

$

Laundry/Dry Cleaning

$

$

Medical and Dental Expenses:

$

$

Car Payment/Lease:

$

$

Transportation Costs (gas, oil, repair):

$

$

Recreation, Entertainment:

$

$

Charitable Contributions:

$

$

Homeowners/Renters Insurance
(not included above):

$

$

Life Insurance:

$

$

Health Insurance (not from payroll):

$

$

Auto Insurance:

$

$

Other Insurance:

$

$

Other Taxes - Personal Property:

$

$

Alimony:

$

$

Credit Card 1:

$

$

Credit Card 2:

$

$

Credit Card 3:

$

$

Credit Card 4:

$

$

Credit Card 5:

$

$

Credit Card 6:

$

$

Credit Card 7:

$

$

Credit Card 8:

$

$

Loan Payment 1:

$

$

Loan Payment 2:

$

$

Loan Payment 3:

$

$

Loan Payment 4:

$

$

Loan payment 5:

$

$

Important Legal Disclaimers:

1. Yes     No
I agree that this matter may be referred to an attorney in my area who may contact me.

2. Yes     No
I agree that by submitting this question, I will not be charged for the initial response. I understand that I am forming only a semi-confidential relationship.

3. Yes - I agree No - I disagree that the above does not constitute a request for legal advice and that I am not forming an attorney client relationship by submitting this question. I understand that I may only retain an attorney by entering into a fee agreement, and that I am not hereby entering into a fee agreement. I agree that the information that I will receive in response to the above question is general information and I will not be charged for the response to this e-mail question. I further understand that the law for each state may vary, and therefore, I will not rely upon this information as legal advice. Since this matter may require advice regarding my home state, I agree that local counsel may be contacted for referral of this matter.