CHAPTER 13 INTAKE QUESTIONNAIRE
Confidential Client Information Form
Law Firm: [FIRM NAME]
Attorney: [ATTORNEY NAME], Esq.
Date of Interview: [DATE]
Intake Specialist: [NAME]
SECTION 1: ELIGIBILITY DETERMINATION
Reference: 11 U.S.C. Section 109(e)
1.1 Chapter 13 Eligibility Requirements
To file Chapter 13, the debtor must be an individual (not a corporation or partnership) with regular income whose debts do not exceed the following limits:
Current Debt Limits (as adjusted under 11 U.S.C. Section 104):
(Verify current limits at time of filing)
| Debt Type | Current Limit | Debtor's Amount | Eligible? |
|---|---|---|---|
| Total Debt (secured + unsecured) | $[CURRENT LIMIT] | $_____________ | ☐ Yes ☐ No |
Note: Effective June 21, 2022, BAPCPA debt limits were replaced with a single combined limit. Verify current limits.
1.2 Regular Income Verification
Does the debtor have "regular income" sufficient to fund a plan?
☐ Yes - Source(s): _________________________________________________
☐ No - Consider Chapter 7 or other alternatives
"Regular income" means income from any source that is sufficiently stable and regular to enable the debtor to make plan payments. This can include:
- Wages/salary
- Self-employment income
- Social Security
- Pension/retirement
- Rental income
- Alimony/child support received
- Contributions from family members
SECTION 2: DEBTOR IDENTIFICATION
2.1 Primary Debtor Information
| Field | Response |
|---|---|
| Full Legal Name | _________________________________ |
| Other Names Used (last 8 years) | _________________________________ |
| Date of Birth | ____/____/________ |
| Social Security Number | _____-_____-_________ |
| Driver's License Number/State | _________________________________ |
2.2 Contact Information
| Field | Response |
|---|---|
| Current Street Address | _________________________________ |
| City, State, ZIP | _________________________________ |
| County of Residence | _________________________________ |
| How long at this address? | _________________________________ |
| Previous Address (if less than 2 years) | _________________________________ |
| Primary Phone | _________________________________ |
| Email Address | _________________________________ |
2.3 Joint Debtor Information (if applicable)
| Field | Response |
|---|---|
| Full Legal Name | _________________________________ |
| Other Names Used | _________________________________ |
| Date of Birth | ____/____/________ |
| Social Security Number | _____-_____-_________ |
| Relationship | ☐ Spouse ☐ Domestic Partner |
SECTION 3: HOUSEHOLD & DEPENDENTS
3.1 Marital Status
☐ Single (never married)
☐ Married - filing jointly
☐ Married - filing individually
☐ Separated
☐ Divorced
☐ Widowed
3.2 Dependents
| Name | Relationship | Age | Lives with Debtor? | Special Needs? |
|---|---|---|---|---|
| _________________ | _____________ | ____ | ☐ Yes ☐ No | ☐ Yes ☐ No |
| _________________ | _____________ | ____ | ☐ Yes ☐ No | ☐ Yes ☐ No |
| _________________ | _____________ | ____ | ☐ Yes ☐ No | ☐ Yes ☐ No |
| _________________ | _____________ | ____ | ☐ Yes ☐ No | ☐ Yes ☐ No |
Total Household Size: _______ persons
SECTION 4: EMPLOYMENT & INCOME
Critical for Plan Payment Calculation
4.1 Current Employment - Debtor 1
| Field | Response |
|---|---|
| Current Employer | _________________________________ |
| Employer Address | _________________________________ |
| Job Title | _________________________________ |
| Date of Hire | ____/____/________ |
| Employment Type | ☐ Full-time ☐ Part-time ☐ Self-employed |
| Gross Monthly Income | $________________ |
| Net Monthly Income (take-home) | $________________ |
| Payroll Frequency | ☐ Weekly ☐ Bi-weekly ☐ Semi-monthly ☐ Monthly |
| Stable employment expected? | ☐ Yes ☐ No - Explain: _____________ |
4.2 Current Employment - Debtor 2 (if joint)
| Field | Response |
|---|---|
| Current Employer | _________________________________ |
| Employer Address | _________________________________ |
| Job Title | _________________________________ |
| Date of Hire | ____/____/________ |
| Employment Type | ☐ Full-time ☐ Part-time ☐ Self-employed |
| Gross Monthly Income | $________________ |
| Net Monthly Income | $________________ |
4.3 Other Income Sources (Monthly)
| Source | Amount | Recipient | Stable? |
|---|---|---|---|
| Self-Employment/Side Business | $________ | ☐ D1 ☐ D2 | ☐ Yes ☐ No |
| Social Security | $________ | ☐ D1 ☐ D2 | ☐ Yes ☐ No |
| Disability (SSI/SSDI/VA) | $________ | ☐ D1 ☐ D2 | ☐ Yes ☐ No |
| Pension/Retirement | $________ | ☐ D1 ☐ D2 | ☐ Yes ☐ No |
| Rental Income | $________ | ☐ D1 ☐ D2 | ☐ Yes ☐ No |
| Child Support Received | $________ | ☐ D1 ☐ D2 | ☐ Yes ☐ No |
| Alimony/Maintenance Received | $________ | ☐ D1 ☐ D2 | ☐ Yes ☐ No |
| Unemployment | $________ | ☐ D1 ☐ D2 | Duration: _______ |
| Family Contributions | $________ | From: ________ | ☐ Yes ☐ No |
| Other: _____________ | $________ | ☐ D1 ☐ D2 | ☐ Yes ☐ No |
TOTAL MONTHLY HOUSEHOLD INCOME: $________________
SECTION 5: MONTHLY EXPENSES
For Schedule J and Plan Feasibility Analysis
5.1 Housing
| Expense | Current Monthly Amount |
|---|---|
| Mortgage Payment (1st) | $_____________ |
| Mortgage Payment (2nd) | $_____________ |
| Rent | $_____________ |
| Property Taxes (if not in mortgage) | $_____________ |
| Homeowners Insurance (if not in mortgage) | $_____________ |
| Mortgage Insurance (if not in mortgage) | $_____________ |
| HOA/Condo Fees | $_____________ |
| Home Maintenance/Repairs | $_____________ |
5.2 Utilities
| Utility | Monthly Amount |
|---|---|
| Electric | $_____________ |
| Gas/Heating | $_____________ |
| Water/Sewer | $_____________ |
| Trash | $_____________ |
| Telephone/Cell Phone | $_____________ |
| Internet | $_____________ |
| Cable/Streaming Services | $_____________ |
5.3 Transportation
| Expense | Monthly Amount |
|---|---|
| Vehicle Payment #1 | $_____________ |
| Vehicle Payment #2 | $_____________ |
| Auto Insurance | $_____________ |
| Fuel | $_____________ |
| Maintenance/Repairs | $_____________ |
| Parking/Tolls | $_____________ |
| Public Transportation | $_____________ |
5.4 Personal & Family
| Expense | Monthly Amount |
|---|---|
| Food/Groceries | $_____________ |
| Clothing | $_____________ |
| Laundry/Dry Cleaning | $_____________ |
| Medical/Dental (out-of-pocket) | $_____________ |
| Prescriptions | $_____________ |
| Health Insurance (if not payroll deducted) | $_____________ |
| Life Insurance | $_____________ |
| Child Care/Daycare | $_____________ |
| Child Education Expenses | $_____________ |
| Entertainment/Recreation | $_____________ |
| Personal Care | $_____________ |
| Pet Care | $_____________ |
| Charitable Contributions | $_____________ |
| Other: _____________ | $_____________ |
5.5 Domestic Support Obligations PAID
| Obligation | Recipient | Monthly Amount |
|---|---|---|
| Child Support | _____________ | $_____________ |
| Spousal Support/Alimony | _____________ | $_____________ |
TOTAL MONTHLY EXPENSES: $________________
SECTION 6: DEBTS REQUIRING SPECIAL TREATMENT IN CHAPTER 13
6.1 Mortgage Arrears (Cure Through Plan)
Reference: 11 U.S.C. Section 1322(b)(5)
| Property | Lender | Arrears Amount | Current Payment |
|---|---|---|---|
| _________________ | _________________ | $_____________ | $_____________ |
| _________________ | _________________ | $_____________ | $_____________ |
Primary Reason for Filing Chapter 13:
☐ Stop foreclosure and cure mortgage arrears
☐ Reduce vehicle payments (cram down)
☐ Pay tax debts over time
☐ Eliminate second mortgage (strip lien)
☐ Pay back child support/alimony
☐ Cannot pass Chapter 7 means test
☐ Protect non-exempt assets
☐ Stop wage garnishment
☐ Other: _____________________________________________
6.2 Vehicle Loans (Potential Cram Down)
Reference: 11 U.S.C. Section 1325(a)
| Vehicle | Lender | Balance | Value | Interest Rate | Purchase Date |
|---|---|---|---|---|---|
| _________________ | _________________ | $_______ | $_______ | ____% | ____/____/____ |
| _________________ | _________________ | $_______ | $_______ | ____% | ____/____/____ |
Cram Down Eligibility: Vehicle must be purchased more than 910 days (approximately 2.5 years) before filing to reduce secured claim to current value.
6.3 Priority Tax Debts
Reference: 11 U.S.C. Section 507(a)(8), 1322(a)(2)
| Taxing Authority | Type | Tax Years | Amount |
|---|---|---|---|
| IRS | ☐ Income ☐ Payroll | _________ | $_____________ |
| State | ☐ Income ☐ Sales | _________ | $_____________ |
| Local | ☐ Property ☐ Other | _________ | $_____________ |
6.4 Domestic Support Obligations Arrears
Reference: 11 U.S.C. Section 507(a)(1), 1322(a)(2)
| Type | Owed To | Arrears Amount |
|---|---|---|
| Child Support | _________________ | $_____________ |
| Alimony | _________________ | $_____________ |
SECTION 7: SECURED DEBTS
For Schedule D and Plan Treatment
7.1 Real Property Secured Debts
| Property | Creditor | Balance | Value | Monthly Payment | Interest Rate |
|---|---|---|---|---|---|
| Primary Residence | _________________ | $_______ | $_______ | $_______ | ____% |
| 2nd Mortgage/HELOC | _________________ | $_______ | N/A | $_______ | ____% |
| Investment Property | _________________ | $_______ | $_______ | $_______ | ____% |
7.2 Personal Property Secured Debts
| Collateral | Creditor | Balance | Value | Monthly Payment |
|---|---|---|---|---|
| _________________ | _________________ | $_______ | $_______ | $_______ |
| _________________ | _________________ | $_______ | $_______ | $_______ |
SECTION 8: UNSECURED DEBTS
8.1 Priority Unsecured (Must be paid 100%)
| Creditor | Type | Amount |
|---|---|---|
| _________________ | ☐ Recent Taxes ☐ DSO Arrears ☐ Other Priority | $_____________ |
| _________________ | ☐ Recent Taxes ☐ DSO Arrears ☐ Other Priority | $_____________ |
TOTAL PRIORITY UNSECURED: $________________
8.2 General Unsecured
| Creditor | Account # | Type | Amount |
|---|---|---|---|
| _________________ | _________ | ☐ Credit Card | $_____________ |
| _________________ | _________ | ☐ Medical | $_____________ |
| _________________ | _________ | ☐ Personal Loan | $_____________ |
| _________________ | _________ | ☐ Collection | $_____________ |
| _________________ | _________ | ☐ Judgment | $_____________ |
| _________________ | _________ | ☐ Other | $_____________ |
TOTAL GENERAL UNSECURED: $________________
8.3 Student Loans (Typically non-dischargeable)
| Servicer | Type | Balance | Monthly Payment |
|---|---|---|---|
| _________________ | ☐ Federal ☐ Private | $_____________ | $_____________ |
| _________________ | ☐ Federal ☐ Private | $_____________ | $_____________ |
SECTION 9: PRIOR BANKRUPTCY HISTORY
9.1 Previous Filings
Have you filed bankruptcy before?
☐ No
☐ Yes - Complete below:
| Case Number | Court | Chapter | Filing Date | Outcome |
|---|---|---|---|---|
| _____________ | _____________ | ☐ 7 ☐ 13 ☐ 11 | ____/____/____ | ☐ Discharged ☐ Dismissed |
Important Bars:
- Chapter 7 discharge within last 4 years: Bars Chapter 13 discharge
- Chapter 13 discharge within last 2 years: Bars Chapter 13 discharge
- Prior case dismissed within 180 days: May limit automatic stay
SECTION 10: PLAN FEASIBILITY ANALYSIS
10.1 Disposable Income Calculation (Preliminary)
Reference: 11 U.S.C. Section 1325(b)(2)
| Item | Amount |
|---|---|
| Total Monthly Income | $_____________ |
| Less: Necessary Living Expenses | ($____________) |
| Less: Ongoing Secured Payments (mortgage, car) | ($____________) |
| Less: Ongoing DSO Payments | ($____________) |
| Preliminary Disposable Income | $_____________ |
10.2 Plan Duration
Reference: 11 U.S.C. Section 1322(d)
Applicable Commitment Period:
☐ Below Median Income: 36 months (may extend to 60 with cause)
☐ Above Median Income: 60 months required
Current Monthly Income (Form 122C-1): $_____________
State Median for Household Size: $_____________
Above or Below Median: ☐ Above ☐ Below
10.3 Plan Payment Estimation
| Plan Component | Monthly Amount |
|---|---|
| Trustee Fee (estimate 10%) | $_____________ |
| Attorney Fees (through plan) | $_____________ |
| Mortgage Arrears Cure | $_____________ |
| Vehicle Payments | $_____________ |
| Priority Tax Debts | $_____________ |
| DSO Arrears | $_____________ |
| Unsecured Dividend | $_____________ |
| ESTIMATED PLAN PAYMENT | $_____________ |
Is Estimated Plan Payment < Disposable Income?
☐ Yes - Plan appears feasible
☐ No - Adjustments needed
SECTION 11: CREDIT COUNSELING
Reference: 11 U.S.C. Section 109(h)
Pre-Filing Credit Counseling
☐ Completed - Date: ____/____/________
Agency: _________________________________
Certificate #: _________________________________
☐ Not yet completed (must complete within 180 days before filing)
SECTION 12: DOCUMENTS CHECKLIST
Required Documents
☐ Pay stubs (last 60 days)
☐ Tax returns (last 2 years)
☐ W-2s (last 2 years)
☐ Bank statements (last 6 months)
☐ Mortgage statements
☐ Vehicle loan statements
☐ All credit card/debt statements
☐ Child support/alimony orders
☐ Photo ID
☐ Social Security cards
☐ Credit counseling certificate
☐ Proof of all income sources
SECTION 13: DEBTOR CERTIFICATION
I/We certify under penalty of perjury that the information provided is true, correct, and complete to the best of my/our knowledge.
Debtor 1 Signature: _________________________________ Date: ____/____/________
Debtor 2 Signature: _________________________________ Date: ____/____/________
ATTORNEY NOTES
_____________________________________________________________________________
_____________________________________________________________________________
Attorney Signature: _________________________________ Date: ____/____/________
Template Version 1.0 - Updated January 2026
References: 11 U.S.C. Sections 109(e), 1322, 1325, 1329; Official Forms 101, 106, 107, 122C
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Last updated: February 2026