Client Intake Questionnaire (Bankruptcy)

1. Client Information

• Full legal name:
• Other names used in past 8 years:
• Date of birth:
• SSN/ITIN (last 4):
• Residential address:
• Mailing address (if different):
• Phone/email:
• Marital status:

2. Household and Dependents

• Spouse/partner name and contact info:
• Household size:
• Dependents (names/ages/relationship):
• Are any dependents not living with you? ☐ Yes ☐ No

3. Bankruptcy Goals and Case Type

• Primary goals (stop garnishment, save home, discharge debt, etc.):
• Preferred chapter (if known): ☐ Chapter 7 ☐ Chapter 13 ☐ Chapter 11 ☐ Other ☐ Not sure
• Urgent deadlines (foreclosure, repossession, eviction, lawsuit):

4. Prior Bankruptcy and Litigation History

• Prior bankruptcy filings? ☐ Yes ☐ No
• If yes: Chapter, year, district, case number, discharge/dismissal:
• Pending lawsuits or judgments? ☐ Yes ☐ No
• Wage garnishments or bank levies? ☐ Yes ☐ No

5. Employment and Income

• Current employer and job title:
• Employment start date:
• Gross monthly income:
• Other income (spouse, benefits, business, rental, support):
• Expected changes in income in next 6-12 months:

6. Assets

Real Property

• Home address and type:
• Estimated value and mortgage balance(s):
• Are you behind on payments? ☐ Yes ☐ No Amount:

Vehicles

• Vehicle(s) year/make/model:
• Estimated value and loan balance(s):
• Any repossession threats? ☐ Yes ☐ No

Personal Property and Financial Accounts

• Bank accounts and balances:
• Retirement accounts:
• Stocks/crypto/other investments:
• Cash on hand:
• Valuable personal property (jewelry, art, collectibles):

7. Debts and Obligations

• Secured debts (mortgage, auto, other collateral):
• Priority debts (taxes, domestic support, wages owed):
• Unsecured debts (credit cards, medical bills, personal loans):
• Student loans:
• Domestic support obligations (amount, payee):

8. Leases and Executory Contracts

• Residential lease? ☐ Yes ☐ No
• Vehicle lease? ☐ Yes ☐ No
• Other executory contracts (cell phone, gym, business contracts):

9. Transfers and Financial Activity

• Transfers of property in last 2 years? ☐ Yes ☐ No
• Payments to relatives or insiders in last 1 year? ☐ Yes ☐ No
• Large payments to any creditor in last 90 days? ☐ Yes ☐ No

10. Business Interests (if any)

• Business name and type:
• Ownership percentage:
• Business debts or lawsuits:
• Business assets and accounts:

11. Credit Counseling and Debtor Education

• Completed credit counseling in last 180 days? ☐ Yes ☐ No
• Completed debtor education course? ☐ Yes ☐ No

12. Documents to Provide

☐ Government ID and Social Security card
☐ Last 6 months of pay stubs or income proof
☐ Last 2 years of tax returns
☐ Bank statements (last 3-6 months)
☐ Mortgage and vehicle statements
☐ Recent bills and collection letters
☐ Lawsuits, judgments, or garnishment notices
☐ Leases and contracts
☐ Retirement account statements
☐ Domestic support orders
☐ Other: ________________________

13. Acknowledgment

• I certify that the information provided is accurate to the best of my knowledge and understand that submission does not create an attorney-client relationship until a written engagement agreement is signed.

Client signature: ____________________________ Date: __________

Intake received by (staff): ____________________ Date: __________