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Bankruptcy Intake Form
Please submit the requested information below for your Free Legal Evaluation. Fields marked with an asterisk (*) are required.
*Name:
*Address:
*City, State, Zip:
*Telephone:
*E-Mail Address:
Debt Info (Credit Cards, Medical Bills, Personal Loans, etc.- totals per category - do not need to list creditor names/amounts)
Vehicle 1 Information (year, make, model plus balance owed,
value, payment & whether payments are current):
Vehicle 2 Information (year, make, model plus balance owed,
value, payment & whether payments are current):
Vehicle 3 Information (year, make, model plus balance owed,
value, payment & whether payments are current):
Real Estate (for each parcel owned: provide value, mortgage balance(s),
payment amount & number of payments behind, if any)
Other Assets (descriptions and values):
Net Income 1 (& pay frequency):
Net Income 2 (& pay frequency):
Comments:
NOTE: The use of the Internet for communications with the firm will not establish an attorney-client relationship and messages containing confidential or time-sensitive information should not be sent.
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