The New Client Intake Form

Name

Please enter your name.

Street Address

Please enter your street address.

City

Please enter the name of your city.

State

Please choose your state of residence.

Select StateAlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWashington DCWest VirginiaWisconsinWyomingZIP Code

Please enter a valid ZIP code. You may use 0-9, spaces and the ( ) – + characters.

E-mail Address

Please enter a valid e-mail address.

Home Phone Number

Please enter a valid home phone number. You may use 0-9, spaces and the ( ) – + characters.

Business Phone Number

Please enter a valid business phone number. You may use 0-9, spaces and the ( ) – + characters.

Mobile Phone Number

Please enter a valid mobile phone number. You may use 0-9, spaces and the ( ) – + characters.

Fax Number

Please enter a valid fax number. You may use 0-9, spaces and the ( ) – + characters.

If you intend to file a joint bankruptcy petition, please enter your name and your spouse’s name, including middle initial.

Please enter your name and your spouse’s name.

If you intend to file a joint bankruptcy petition, please list your residence address, including the county.

Please list your residence address, including the county.

If you intend to file a joint bankruptcy petition, how long have you been at this address?

Please indicate how long have you been at this address.

If you intend to file a joint bankruptcy petition, please list any other residences and how long you have owned them.

Please list any other residences and how long you have owned them.

If you have used any other name(s) in the last six years, please enter those name(s).

Please enter any other name(s) you’ve used.

If you are married, how long have you been married?

Please indicate how long you have been married.

If you are divorced, how long it has been since your divorce?

Please indicate how long it has been since your divorce.

If you live with any minor children, please enter their birth dates.

Please enter the birth dates of any minor children living with you.

If any child support payments are past due, please enter the past-due balance.

Please enter the past-due balance on your child support payments.

If you are receiving income from other sources (e.g. second job, investments, social security, child support, worker’s compensation, rental income, etc.), please enter the source and the amount.

Please enter the source and the amount of income received from other sources.

If you owe money to the Internal Revenue Service, how many years have you owed money to the IRS?

How many years have you owed money to the IRS?

If you owe money to the Internal Revenue Service, how much money do you owe to the IRS?

How much money do you owe to the IRS?

If you have unpaid student loans, please enter the unpaid balance.

Please enter the unpaid balance of your student loans.

If you pay anyone spousal support (alimony), please enter the name(s) of the recipient and the amount you pay.

Please enter the name(s) of the recipient(s) and the amount you pay to each in spousal support.

Please enter your tax assessed value.

Please enter your tax assessed value.

If you are facing foreclosure, please enter the foreclosure date.

Please enter the foreclosure date.

Please enter any liens against your property.

Please enter any liens against your property. A lien is a legal claim against a property, such as for unpaid bills for home improvements.

Please enter your creditors names.

Please enter your creditors’ names.

Please enter the estimated balance owed on your medical bills.

Please enter the estimated balance owed on your medical bills.

Please enter the estimated balance owed on overdraft or NSF (not sufficient funds) checks.

Please enter the estimated balance owed on NSF checks.

Please enter the total estimated balance owed on all credit cards.

Please enter the estimated balance owed on all credit cards.

Please enter the estimated balance owed on miscellaneous bills.

Please enter the estimated balance owed on miscellaneous bills.

Please enter approximate date of the last time you used any of your credit cards.

Please enter approximate date of the last time you used any of your credit cards.

Please enter how much total owed on cards has increased in the last 12 months.

Please enter how much total owed on cards has increased in the last 12 months.

If you are anticipating a tax refund, please enter the anticipated amount.

Please enter the anticipated amount of your tax refund.

If you are eligible for the Earned Income Credit, please enter the amount.

Please enter the amount of Earned Income Credit.

Please list all judgments, lawsuits, liens and garnishments against you.

Please list all judgments, lawsuits, liens and garnishments against you.

Describe any special concerns.

Please describe any special concerns.

How did you hear about this Web site?

How did you hear about this Web site? Please choose one.

Select oneTelevision AdRadio AdNewspaper AdBillboardsReferred by a FriendSearch EngineOtherThe use of the Internet or this form for communication with the firm or any individual member of the firm does not establish an attorney-client relationship. Confidential or time-sensitive information should not be sent through this form.