Free Intake Form for Free Initial Consultation

In order for us to discuss your case, please thoroughly fill out the following information as soon as possible so that we may review the best course of action for your specific situation. All fields are required. If a particular question doesn’t apply, please simply enter a hyphen (-) and move on to the next. [contactform email=”utoffice09@hendersonlaw.org” subject=”Bankruptcy Initial Intake Form” success=”Thank you. Your form has been submitted”] [textfield label=”Is Quick Chek one of your creditors?” required=”true”] [textfield label=”Have you been receiving any harassing phone calls from creditors? (i.e. before 9am or after 9pm, at work, threats, etc.)” required=”true”] [textfield label=”Phone Number” required=”true”] [email label=”Email Address” required=”true”] [name label=”Name” required=”true”] [textarea label=”Current Address (Include County)” required=”true”] [textarea label=”Two Previous Addresses (Address, City, State, Zip Code, Amount of time lived in each location)” required=”true”] [textfield label=”Number of people sleeping at current address? How many of them are listed on your tax return?” required=”true”] [textfield label=”Total Number of Creditors and Total Deb Amount (Approximate)” required=”true”] [textfield label=”Are you being Garnished?” required=”true”] [textfield label=”Have you ever filed for Bankruptcy before? If so, when and what chapter?” required=”true”] [textfield label=”Will you be filing a joint petition of bankruptcy? (i.e. you and your spouse)” required=”true”] [textfield label=”Have you incurred any debt in the last 90 days? If so, how much and to whom?” required=”true”] [textfield label=”Have you paid a creditor more than $600 in the last 90 days? If so, how much and to whom?” required=”true”] [textfield label=”Have any family members loaned you money? If so, how much and to whom?” required=”true”] [textfield label=”Have you filed taxes in the last 6 years? Do you have copies of your taxes for the last 3 years?” required=”true”] [textfield label=”If married, did you file jointly in each of the last 3 years? If no, what years did you?” required=”true”] [textfield label=”Do you owe any money in back taxes? If yes, how much and in what years?” required=”true”] [textfield label=”Do you rent, own a home, condominium, vacant lot or mobile home?” required=”true”] [textfield label=”What is the value of your home?” required=”true”] [textfield label=”What are your monthly payments and what is your pay-off amount on your mortgage?” required=”true”] [textfield label=”Are you behind in your payments? If so, what months?” required=”true”] [textfield label=”Is there a second mortgage on the real estate?” required=”true”] [textfield label=”What are the monthly payments and what is the pay-off amount on this mortgage?” required=”true”] [textfield label=”Are you behind on these payments?” required=”true”] [textfield label=”How many vehicles do you own?” required=”true”] [textfield label=”Vehicle 1 (Year, make, model, mileage, condition, est. value)” required=”true”] [textfield label=”Do you intend to keep or surrender Vehicle 1?” required=”true”] [textfield label=”Have you listed Vehicle 1 as collateral for a loan?” required=”true”] [textfield label=”Vehicle 2 (Year, make, model, mileage, condition, est. value)”] [textfield label=”Do you intend to keep or surrender Vehicle 2?”] [textfield label=”Have you listed Vehicle 2 as collateral for a loan?”] [textfield label=”What was your gross income for last year?” required=”true”] [textfield label=”What was your gross income for the year before last?” required=”true”] [textfield label=”What is the frequency of your current income received? (weekly, bi-weekly, monthly, semi-monthly)” required=”true”] [textfield label=”Please list your gross average paycheck amount.” required=”true”] [textfield label=”What is the frequency of your spouses current income? (weekly, bi-weekly, monthly, semi-monthly)” required=”true”] [textfield label=”Please list your spouse’s gross average paycheck amount.” required=”true”] [textfield label=”After paying your monthly bills, how much money do you have left over?” required=”true”] [/contactform] Once you have thoroughly completed all of the required information on the above form, click submit and your responses will be submitted.