Free evaluation

Thank you for choosing our law firm to assist you with your financial needs. Please fill out this form with as much detail as possible. All information you provide will be kept in the strictest confidence. When you have finished filling out this form, return to us for the attorney to review. We look forward to helping you achieve your financial goals and get a fresh start to a better financial future.

Date

Total Number of People Living in Your Household

Your Name

Name of Spouse (if applicable)

Address

City

State

Zip

Home Phone

Work

Cell

Email Address

Would you like to receive our free newsletter that we mail to our clients?

YesNo

YOUR INCOME

How much money do you make, or gross, every paycheck (before taxes and deductions)?

How often do you get paid?

EVERY 2 WEEKSMONTHLYTWICE A MONTHWEEKLY

How much money does YOUR SPOUSE make every paycheck (before taxes and deductions)?

How often does YOUR SPOUSE get paid?

EVERY 2 WEEKSMONTHLYTWICE A MONTHWEEKLY

How much social security do you receive per month?

How much child support do you receive per month?

How much retirement income do you receive per month?

How much additional money do you earn per month?

MONTHLY LIVING EXPENSES

Please provide an AVERAGE amount that your household pays PER MONTH for the following expenses:

Mortgage or Rent

Garbage Pick-Up

Electricity

Lawn Maintenance

Water and sewer

Pool Maintenance

Home Phone

Other Expenses

Cell Phone

Recreation

Food

Motor Vehicle Payment #1

Clothing

Motor Vehicle Payment #2

Laundry

Motor Vehicle Payment #3

Gasoline for Motor Vehicles

Student Loan

Home/Renters Insurance

Furniture Paymente

Life Insurance

Jewelry Payment

Auto Insurance

Boat and RV

Income Taxes
(not deducted from paycheck)

Child Care

Real Estate Taxes(not included in mortgage payment)

Infant Expenses

Past Due Taxes

Payments to a family member

What specific debts are you having
the most difficult time with?

Do you expect to lose your job any time soon?

YesNo

Do you expect your income or expenses to change in the near future?

YesNo

Are you paying expenses for someone other than your legal dependent(s)?

YesNo

What goal would you like to achieve
by hiring this law firm to represent you?

STATEMENT OF ACCURACY

CHECK BOXIMPORTANT: CHECK BOX IF YOU AGREE TO THE FOLLOWING STATEMENT

By checking this box you state the information on this Initial Intake Form is true and correct to the best of my/our knowledge. I/We understand that providing inaccurate information can detrimentally affect my/our case, cause an undue outcome or result in charges brought against me/us if convicted of fraud. I/We also understand the information provided in this Initial Intake Form will not be shared with any other party, other than attorneys who have the knowledge to legally advise me/us and authorized parties assigned by the attorneys to work on my/our case.

Have you ever filed bankruptcy before?	YesNo
If so, in what year?	Year
Do you own a home or other real estate?	YesNo
Are you behind in your mortgage payments?	YesNo
If so, how many months are you behind?	Months
Do you own a mobile home?	YesNo
Do you receive bonuses at your work?	YesNo
Do you receive commissions or tips at your work?	YesNo
Do you own any cars, motorcycles, vans, RVs or other vehicles?	YesNo
If so, how many vehicles do you own outright?	Vehicles
If so, how many vehicles do you make payments on?	Vehicles
Have you filed all of your income tax returns for this year and the past 3 years?	YesNo
Do you owe the IRS any past due taxes?	YesNo
Do you owe any unpaid state taxes?	YesNo
Do you owe any unpaid property taxes?	YesNo
Do you owe on a student loan?	YesNo
Have you borrowed money from your IRA or other retirement plan to pay bills?	YesNo
Have you received any cash advances within the past 3 months?	YesNo
Do you have any loans with a credit union where you work?	YesNo
Are you leasing any buildings or equipment?	YesNo
Does an ex-spouse have a claim against you for any reason?	YesNo
Do you owe money on the purchase of jewelry, furniture or other household goods?	YesNo
Have you experienced, or do you expect to experience a foreclosure or repossession?	YesNo
Are you in the process of suing someone?	YesNo
Does anyone want to sue you or have they already filed a lawsuit against you?	YesNo
Does anyone have a claim against you due to a car accident?	YesNo
Have you used your credit cards to make purchases within the past 90 days?	YesNo
During the past 2 years,have you owned or had an interest in any business?	YesNo
Have you transferred any property with a retail value of $600 or more within the past 4 years? This includes homes, motor vehicles and other assets.	YesNo
Have you stopped using all your credit cards?	YesNo
Do you have any credit cards you want to hold on to for an emergency?	YesNo
Are you behind in child support?	YesNo
Do you have any payday loans you still owe money for?	YesNo
Have you closed any bank accounts and left owing a balance?	YesNo
Do you have any bounced checks you owe additional fees for?	YesNo
Do you have any co-signers for your debts other than your spouse (if applicable)?	YesNo
Have you co-signed a loan for anyone other than your spouse (if applicable)?	YesNo
Are your wages currently being (or are soon to be) garnished?	YesNo
Do you have any judgments against you from any lawsuits that you lost?	YesNo
Do you have any lawsuits against you where the case is still pending?	YesNo
Do you have CDs, stocks, bonds or other types of financial accounts?	YesNo
Are you self-employed?	YesNo
If so, how long have you been self-employed?	Months
Are you currently drawing unemployment, retirement and/ or social security disability?	YesNo
Are you continuing to get new credit cards to cover essential living expenses?	YesNo
Are you borrowing money from friends/family to cover your debts?	YesNo

Call now

(216) 502-1300

Free evaluation

INITIAL INTAKE FORM

Please answer the following "yes" and "no" questions. All information will be kept in the strictest confidence.

YOUR INCOME

MONTHLY LIVING EXPENSES

Please provide an AVERAGE amount that your household pays PER MONTH for the following expenses:

STATEMENT OF ACCURACY