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* Last Name:

* First Name:

Middle Name:

Address:

City:

State:

Zip Code:

Telephone:

Home:  

Office:  

Cell:  

Fax:  

* E-mail:  

Which of the above way(s) of contact do you prefer?:

Home

 

Office

 

Cell

 

E-mail

Are you married? Yes     No



Which of the following debts do you owe? Please click on the correct answer and fill in all the blanks that apply to your case.

Home Mortgage      Any arrears?   Yes   No

How many months behind?  

Car Payment #1      Any past due payments?   Yes   No

Year & type of car 1 

Car Payment #2      Any past due payments?   Yes   No

Year & type of car 2 

 Student Loans (most student loans cannot be eliminated by
       bankruptcy)

IRS back taxes - what years?  

State taxes: describe  

Credit card debts       Approximate total amount $

Department store debts

Medical Bills

Boat, motor and or trailer

Lawsuits

Judgements

Real estate back taxes

Child Support    $ monthly

Other debts not included above.  describe



Which of the following assets do you own? Please click on the correct answer and fill in all the blanks that apply to your case.

Home  Do you intend to keep & pay your home? Yes No

Amount owe on mortgage $  Value of home $

Car #1 Do you intend to keep & pay your vehicle? Yes No

Car #2  Do you intend to keep & pay your vehicle? Yes No

Car #3           Do you owe money on this vehicle? Yes No

Lot or Acreage

Boat Motor or Trailer

Rent House

Savings account    Approximate amount in account $

Checking account  Approximate amount in account $

Stocks & Bonds        Approximate value $

Tax refund currently owed to you by IRS

Income tax refund amount currently owed to you
by IRS $

Any other assets worth over $1,000: describe  

IRA's $  or Retirement $

Life insurance policies, term or whole life

Lawsuit you filed against a company or individual

Potential lawsuit against a company or individual, not yet filed



Income. Please click on the correct answer and fill in all the blanks that apply to your case.

I am currently employed

How much do you bring home monthly in wages(net)$

I have a spouse who is currently employed?

How much does your spouse bring home monthly $

I am currently receiving social security or retirement.

If yes, how much a month $

I or my spouse is receiving child support.

How much a month? $

I receive any other income. Please describe

I own a business. Name of business

Type of business

Incorporated   Yes No

DBA   Yes No

Partnership   Yes No


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Indiana Bankruptcy Law Firm

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