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Name
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Phone Number (If you don't want me to contact you by phone, write "none" and provide your e-mail instead in this form)
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E-mail (If you don't have an e-mail, write "none" but be sure to give me your phone number in this form)
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City where you live
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Ever filed bankruptcy before?
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If so, what year?
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Have you sold or purchased a home within the last 1 year?
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Have you transferred a title or deed to a relative or close friend within the last 2 years?
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Have you transferred money or paid off a loan to a relative or close friend within the last 2 years?
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Have you received any non-work-related lump sum of money (gift, award, tax refund) over $5,000 in the last 6 months?
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Are you expecting to receive a judgment, award, or other lump sum money amount over $5,000 in the next 6 months?
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How many automobiles do you have with your name on the title?
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Of those automobiles, how many do you still owe money on?
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Do you own a boat, motorcycle, tractor or travel trailer?
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Do you own any stocks, bonds or other investments outside of a retirement account?
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Do you own the home you live in?
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Do you own land other than the land you live on?
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Have you been employed within the last 6 months?
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If so, did you change, start of lose jobs within the 6 months?
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Have you been self-employed or owned a business within the last 5 years?
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What is your current gross income from work per month?
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Are you currently living with a spouse or other adult?
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If so, what is that person's current gross income per month?
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How much did you report as your gross income on last year's taxes (if you are/were married, combined with spouse's income)?
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How many children under 18 reside in your home with you?
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How much do you and/or a spouse residing with you receive, if anything, for child support?
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How much is your monthly mortgage/rent payment?
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How much are your total monthly automobile payments, if any?
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How much do you pay each month for boats, motorcycles, tractors and travel trailers?
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How much do you spend each month on uninsured prescription medications?
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How much do you pay each month, if anything, for child care expenses?
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How much do you pay each month, if anything, for alimony and/or child support for children living outside your home?
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How much do you pay, if anything, each month toward student loans?
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Do you plan to file bankruptcy within the next month?
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If you retain me, do you wish to meet me in my office or retain me by mail?
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