YOUR SPOUSE CLIENT INTAKE FORM. CONTACT INFORMATION: HOME: ( ) CELL: ( ) MAILING ADDRESS (Include City, State, Zip):
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1 COHEN LAW OFFICES 1149 Municipal Drive 4076 Market Street PO Box 663 Franklin County Suite 209 Duncansville, PA Chambersburg, PA Camp Hill, PA Tel: (814) Tel: (717) Tel: (717) Fax: (814) Fax: (717) CLIENT INTAKE FORM Your Appointment Date: _ YOU FULL NAME (Last, First and Middle): Your Appointment Time: _ YOUR SPOUSE FULL NAME (Last, First and Middle): SOCIAL SECURITY NO: DATE OF BIRTH: PHYSICAL ADDRESS: SOCIAL SECURITY NO: DATE OF BIRTH: PHYSICAL ADDRESS: CONTACT INFORMATION: HOME: ( ) CELL: ( ) MAILING ADDRESS (Include City, State, Zip): CONTACT INFORMATION: HOME: ( ) CELL: ( ) MAILING ADDRESS (Include City, State, Zip): COUNTY OF RESIDENCE: EMPLOYER: EMPLOYER S ADDRESS: COUNTY OF RESIDENCE: EMPLOYER: EMPLOYER S ADDRESS: WORK TELEPHONE NUMBER: ( ) Extension: WORK TELEPHONE NUMBER: ( ) Extension: SELF-EMPLOYED? YES NO SELF-EMPLOYED? YES NO OCCUPATION / JOB TITLE: OCCUPATION / JOB TITLE: LENGTH OF EMPLOYMENT: LENGTH OF EMPLOYMENT: Marital status? Married Never Married Divorced Separated Widowed Do you have dependents? Yes (how many: ages: ) Have You Ever Filed Bankruptcy Before? Yes If Yes, When? Did You Move to this State Within the Past Two Years? Yes If Yes, Prior State: Are you Currently Facing? Repossession Wage Garnishment Foreclosure/Eviction ne Are you paying on or do you own a home? Yes
2 Has Your Home Been Scheduled for Foreclosure? Yes (When ) Has Your Home EVER Been Scheduled for Foreclosure? Yes Do you own any other property (rental or otherwise) or land? Yes Address: Address: Do you receive child support? Yes ( per week/month) Does your spouse receive child support? Yes ( per week/month) Do you pay child support? Yes ( per week/month) Does your spouse pay child support? Yes ( per week/month) Do you receive Social Security/SSI/SSD? Yes ( per month) Does your spouse receive Social Security/SSI/SSD? Yes ( per month) Does any child of yours receive Social Security/SSI/SSD? Yes ( per month) Do you receive Unemployment Compensation? Yes ( per week) Does your spouse receive Unemployment Compensation? Yes ( per week) Do you receive Workers Compensation? Yes ( per week) Does your spouse receive Workers Compensation? Yes ( per week) Do you receive a Pension? Yes ( per week) Does your spouse receive a Pension? Yes ( per week) Do you receive rental income? Yes ( per month Do you own a business? Yes (sole proprietor/llc/corporation/partnership) Does your spouse own a business? Yes (sole proprietor/llc/corporation/partnership) How much income is received from your business? How much income is received from your spouse s business? per week/month per week/month How Did You Hear about Cohen Law Offices? I am a Client Radio Newspaper Placemat Phone Book: Verizon Yellow Book EZ To Use Embarq Internet Referred by: TotalBankruptcy Bankruptcy.Me lo FOR OFFICE USE ONLY
3 In State 2 Years? Y N Prior: Prior Chapter 7 (when) In District 91 Days? Y N Prior: Prior Chapter 13 (when) Household Size? Other Adults? INCOME AVG MONTHLY MONTHLY FREQ SOURCE NET GROSS NET DEBTOR SPOUSE Withholding Change w/in 6 Mos? Income Change w/in 6 Mos? Over Median PAYMENT ARREARS DUE TOTALS CREDITOR CLASS PAYOFF NOTES Self-Employed Inc Yr St SHs/Prtnrs: Emplees: PubPrems: _ Assets: Gross/mo K Exp/mo _ K DESCRIPTION OF SECURITY ref/red/s/al fmv pm/npm u/s n/d date residence acquired (3.3yr) date auto/furn incurred (2.5/1yr) Pmts to Mort: Houses / Land / Autos / Boat / 401k / IRA / Recommendation/Fee 13 7 O Wait til Annuity / Svs / Stocks / HHG / Liq / Jwlry / Guns / Collex / Min Eval: Min to File Plan / Music Inst / Cmcl Ppty / Tools / Anim / X-fersW / in4yrs / Trust / Cashouts / Pmts-GiftsToFrnds-Fam / A-R / DivDec / LifEInsVal / /pp PRDO H W InterestInBus / PptyHeldByOtr / Otr / Storage / Losses Plan / /mo for / /mos Due (min) / (max) (min) / (max) Contingent Legal Claims: Inheritance Rjcted w/in 4 Yrs or Exmpted w/in 6 mos: Returns Not Filed: Last Ref Amt: Ref Exempted: Previously Filed BKs: CCC: Y N % CC Debt w/in Yr: Cash Advance: w/in 75 Days Otr FS Given w/in Yr: Remarks: PMTS REM CS GARN LEVY ASGMT IRA/401K ST PEN CONTR REPAY CS/ALIM CO Cmcl Ppty Cashcol TS EVER? 1 MTG 2 MTG 3 MTG HOA Ppty Tax Otr RE Auto Boat CUCC PMSI DurGds Jewelry DeptStore NPMSI Taxes SL Div/Sep Meds RepoDef Apts Suits MVA CC Store CCs LOC Pers Prof Ins Prem Tuition Benf Ovrpy PayDay NSF O/D Utils Mail Order
4 CURRENT EXPENSES Do you or your spouse maintain separate households? Y N If so, please fill one page out for your household and another for your spouse s. Indicate how much you pay for each item each month. If you do not pay anything, please indicate it with a 0 or -, DO NOT leave it blank. If you are unsure of the amount you pay each month, but know the amount for a different period (per week, per day, every 3 months, etc.), write in the amount and the frequency that you pay the amount. 1. Your rent/lot rent/homeowners association fee 2. Your first mortgage Does your mortgage pmt include real estate taxes? Y N Does your mortgage pmt include property insurance? Y N 3. Your second mortgage or line of credit 4. Rent/Mortgage payments for another property 5. Electricity 6. Gas/heating oil/propane 7. Water 8. Sewer 9. Landline telephone 10. Cell phone 11. Garbage 12 Cable/DirectTV/Satellite TV 13. Internet 14. Home repairs and upkeep (yearly) 15. Food 16. Clothing (yearly) 17. Laundry detergents/laundromat/dry cleaning 18. Medical Pmts/Prescriptions not covered by insurance (i.e., co-pays) 19. Dental and Vision Appts/Glasses not covered by insurance 20. Gasoline/car maintenance/inspections/registration (weekly) 21. Entertainment (i.e., movies/eating out/newspapers/magazines) 22. Tithing to church/synagogue/charitable contributions (weekly)
5 23. Insurance not deducted from paychecks or included in mortgage pmt: a) Homeowners or renters insurance b) Life insurance ( term whole life) c) Health insurance d) Automobile insurance e) Other insurance (such as cancer or accident) 24. Taxes not deducted from paychecks (such as local taxes) 25. Automobile payments (indicate yr & model & bank name): 26. Furniture/appliance payments (indicate type & bank): 27. Camper/ATV/Motorcycle/Other installment payments: 28. Alimony, maintenance, child or spousal support paid to others: Name & address of person paid: 29. Payments for dependents not living at home (i.e., college student) 30. Education for a mentally or physically challenged child 31. Private education/catholic school tuition 32. Childcare (weekly) 33. School lunches (weekly) 34. Cigarettes (weekly) 35. Pet food/vet bills/medicine/grooming expenses 36. Business expenses 37. Other expense not listed above Please indicate whether you have any extraordinary expenses due to a medical condition or commute to a long distance job, etc.
YOUR SPOUSE CLIENT INTAKE FORM. CONTACT INFORMATION: HOME: ( ) CELL: ( ) MAILING ADDRESS (Include City, State, Zip):
COHEN LAW OFFICES 1149 Municipal Drive 4076 Market Street PO Box 663 Franklin County Suite 209 Duncansville, PA 16635 Chambersburg, PA 17201 Camp Hill, PA 17011 Tel: (814) 693-0500 Tel: (717) 709-0500
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