Bankruptcy Intake Worksheet. Section I (General Client Information)

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Robyn Gaines
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1 Bankruptcy Intake Worksheet It is very important that you complete this worksheet in its entirety. If something does not apply, leave blank. Be as detailed as possible. Provide all information requested. If you don t there will be a delay in filing your bankruptcy. If you are self-employed please call the office and ask for a BUSINESS INTAKE/EXPENSE WORKSHEET which you will also need to complete. We need a copy of your vehicle insurance or registration card, your state ID or Drivers license and a copy of our social security card. Date: Section I (General Client Information) Have you ever filed for Bankruptcy before? Y N If Yes, date, case #, where filed: Your Name: First Middle Name Maiden Name Last Name Any other name used in the last 8 years? Y N If yes, please list S S Number: Date of Birth: Phone: (H) (W) Cell Phone: address: Are you: Married /Divorced/Separated /Single (circle one) Spouse Name (Only if filing) First Middle Name Maiden Name Last Name S S Number: Date of Birth: Cell Phone Is spouse filing? Yes/ No Street/ Address: County: City/State/Zip: Mailing Address (If different): How long have you lived at this address? If less than 3 years, what was your previous address? Years of occupancy at previous address? Are you Buying /Renting your home? (circle one) If buying, whose name is it in? Me one) Other: When did you first buy? # of Acres: House or Mobile Home (Circle one) Spouse Both (circle If you live in a Manufactured or Mobile Home please tell us: (a. Yr/Make: (b. Model: (c. VIN#: (d. Dimensions: Do you own the land that your manufactured/mobile home is located? Yes No (a. Acres: Land/Home Package? Yes No Part of Mortgage? Yes No (b. Total market value: $ If you owe money on your House or Mobile Home, please tell us: (a. Approx. Payoff: $ (b. Monthly Payment $ (c. Name of creditor: (d. Are you behind on your payments? Yes No ( months) (e. Keep or surrender? (circle one)

2 Do you have a 2nd mortgage or home equity line of credit? Yes No If yes, who is the mortgage holder? Approximate balance due? $ Monthly payment? $ Are you behind on your payments? Yes No ( months) Do you own any land besides the land your house is on? Yes No Location: Acres: Total market value: $ Is this other land mortgaged? Yes No Mortgage Holder? Balance Due: $ Payment? $ Are you behind on the payments? Y N (circle one) Keep Surrender (circle one) We need to know about your personal property and possessions Please list all vehicles you own or lease (whether or not they are working) Year: Make: Model: VIN: Lease Buying Own (circle one) Do you have the title? YES NO Approximate mileage: Condition of vehicle: Excellent/Fair/Poor-not running Name and address of Finance Co.: When purchased? Monthly payment: $ Approximate payoff? $ Behind on your payments? Yes No (How many months? Keep Surrender (circle one) 2 nd Vehicle: Year: Make: Model: VIN: Lease Buying Own (circle one) Do you have the title? YES NO Name and address of Finance Co.: When purchased? Monthly payment: $ Approximate payoff? $ Approximate mileage: Condition of vehicle: Excellent/Fair/Poor-not running Behind on your payments? Yes No (How many months? Keep Surrender (circle one) PLEASE LIST ANY OTHER VEHICLES YOU OWN ON A SEPARATE SHEET OF PAPER. PLEASE ANSWER THE ABOVE QUESTIONS FOR EVERY VEHICLE INCLUDING MOTORCYCLES, BOATS, MOTORS AND TRAILERS Are you paying for any furniture or appliances that you bought on credit? Yes/No Name and Address of Creditor: Balance due: $ Monthly Pmt $ Purchase Date: Description of items purchased: Behind on your payments: Y N ( Months) Do you plan to: Keep Surrender (circle one) PLEASE LIST ANY OTHER FURNITURE PURCHASE ACCOUNTS ON A SEPARATE SHEET OF PAPER. PLEASE ANSWER THE ABOVE QUESTIONS FOR EVERY ACCOUNT Do you have a bank account? Checking Acct #: Savings Acct #: Name(s on the account? Bank: PLEASE LIST ANY OTHER BANK ACCOUNTS ON A SEPARATE SHEET OF PAPER. PLEASE ANSWER THE ABOVE QUESTIONS FOR EVERY BANK ACCOUNT Retirement/401(K) plan? (Circle One) Yes No Who with: Value $ Do You have a loan against your 401(k)? Yes No Please explain how much and how you are paying it back. (i.e. through employer, weekly payments of $ ). (Please provide us with your loan documents). Life Insurance? If yes, what company? Policy #: Value $ Benificiary: Could you cash it in? Y N For how much? $

3 Have you filed your income tax returns for this year? Yes No a. When? b. Amount of refund $ If you have not filed, please tell us why. If you owe the IRS please give us the following information: What years: Balance owed for each year: $ (Please provide us with documentation from the IRS. Please tell us about other property you own that is not financed: Furniture: (Quantity) TV VCR Stereo/Radio DVD Player CD Player Guns/hobby equipment: Value: $ (Please be specific when listing any firearms with brand, type,.ga, etc. Use another sheet if necessary) Furs/Jewelry Value: $ Stocks/Bonds/Safe Deposit Boxes? (Please list, include location and Value: Have you had any closed bank accounts within the last year? Yes No 1. Name and address of financial institution: 2. Checking/Savings Acct #: 3. Balance before closing and date of closing: Sold or given away any property or put any property in someone else's name in the last 6 years? Yes No Describe the property Name and address of the person you sold or gave the property to: Date: Amt Received: $ Value of Property: $ Do you have any property of any kind in your possession that belongs to someone else? YES NO Please describe Name and address of owner Have you given any property to anyone to hold for you while you go through bankruptcy? YES NO Describe Value $ Name and address of holder Do you have any claims against any insurance company because you were in a car accident, had an on-thejob injury, or other lawsuit for which you have hired a lawyer to get you money? YES NO Name & address of attorney: Have you received any money from any insurance company from lawsuits, automobile wreck or workers comp claims in the last six months? Y N Amount received $ Section III (Description of Main Debts) OTHER THAN THE HOME LOAN OR CAR LOAN YOU HAVE ALREADY TOLD US ABOUT, WHAT IS YOUR MAIN DEBT PROBLEM? (CHECK ALL THAT APPLY) CREDIT CARDS Total credit card debt? MEDICAL BILLS Total medical bill debt? (Provide the bills from your medical providers) OTHER (Please describe) STUDENT LOANS Balance Do you owe any child support/alimony? Yes No If current, please tell us your monthly payment $ If behind, please tell us: Amount owed: _ How many months behind? Name and address of who you are sending payments to:

4 Has anyone co-signed for you on any of your debts? Yes No Name and address of co-signer: Is the co-signer a relative? YES/NO Balance due on Debt: Name and address of creditor: Have you had any property repossessed? Yes No Description of property: Date of repossession: Value of property: $ Value sold at: _ Who received property: Address: Amount of deficiency balance: $ Do you currently have any judgments, lawsuits pending or papers served? Yes No (If yes, please provide us with the paperwork. What is the lawsuit about?: County: When were you served with a summons? Section IV (Employment/Income/Dependents) (A) If you are currently employed, tell us where you work: Job Title: How long: Approx take home pay: How often are you paid? Monthly/bi-monthly/weekly/bi-weekly/other (B) Tell us where your spouse is employed? Job Title: How long: Approx take home pay: How often is your spouse paid? Monthly/bi-monthly/weekly/bi-weekly/other: (C) If unemployed please tell us: When you became unemployed: Do you collect unemployment? Yes No How much? $ When will your unemployment end? (Please provide us with documentation of beginning and ending of your unemployment benefits.) PLEASE NOTE THAT IF YOU OR YOUR SPOUSE ARE SELF-EMPLOYED, YOU WILL NEED TO ATTACH YOUR PREVIOUS SIX MONTH'S INCOME STATEMENT AND COMPLETE A BUSINESS INCOME/EXPENSE SHEET (CALL OUR OFFICE TO OBTAIN ONE.) (C) Do you have any dependents/children living in the home? Yes/No SON DAUGHTER::Age: (D) Please check any of these that you receive and tell us how much per month you get: Child support: $ Alimony: Social Security Disability Retirement/Pension Food Stamps Rental income (For what property? ) Section V. (Monthly Living Expenses) Rent/mortgage payment: Taxes Included? YES/NO $ Insurance Included? YES/NO $ Home maintenance: Utilities: Electricity/heating fuel: $ Water & sewer: Phone/CellPhone/Cable/Internet: $ Food/Groceries: Clothing: Laundry/Dry cleaning: Medical/Dental: (NOT INCLUDING INSURANCE PAYMENTS) Transportation (gas)

5 Entertainment: Other Insurance: Auto: Life (not taken out at work) Health insurance: Day care: Charitable Contributions: $ Lot Rent: $ School/Education $ Other expenses not listed above: Please explain any changes in your living situation, expenses and income that you know are going to take place in the next three to six months: Please give us any other information that you might feel is pertinent to your bankruptcy.

LEIDEN AND LEIDEN A Professional Corporation

LEIDEN AND LEIDEN A Professional Corporation Terrance Patrick Leiden (also Ohio) 330 Telfair Street C. Christopher CoCroft, Jr. Zane P. Leiden (also SC) Augusta, Georgia 30901-2450 (1941-1974) (706) 724-8548