Client Form

Client Information

Name*

First Middle Last

How did you hear about us?*

Yellow Pages
Internet
Referral

Birth Date*

Birth City

Home Phone

Cell Phone*

Email*

Physical Address*

Street Address Address Line 2 City State ZIP Code

Mailing Address (If other than above)

Street Address Address Line 2 City State ZIP Code

Employer

Employer Phone

Payroll Address

Street Address Address Line 2 City State ZIP Code

Occupation

Pay Period

Length of Employment

Spouse Information

Do you you have a spouse?*

Yes
No

Name

First Middle Last

Birth Date

Birth City

Physical Address

Street Address Address Line 2 City State ZIP Code

Mailing Address (If other than above)

Street Address Address Line 2 City State ZIP Code

Home Phone

Cell Phone

Email

Payroll Address

Street Address Address Line 2 City State ZIP Code

Employer

Employer Phone

Pay Period

Length of Employment

Occupation

PRIOR BANKRUPTCY CASES:

Where

When

Case#

Where

When

Case#

NAMES USED IN THE PAST 8 YEARS:

PREVIOUS ADDRESSES FOR LAST TWO YEARS (other than above):

MONTHLY BUDGET

This form is necessary to determine how much you spend each month on living expenses. Be sure to write in the MONTHLY (not yearly) amounts in the spaces below each expenditure. For utilities, your bill may be higher in some seasons than others, so write an amount that is “average” covering the whole 12 month period.

Housing Expenses

1st mortgage, mobile home or rent

2nd mortgage payment

Lot payment (if applicable)

Real Estate Taxes (if not included in mortgage payment)

Property, homeowner or renter insurance (if not included in mortgage payment)

Home Maintenance

Homeowner Association or condo dues

Utilities

Electricity and/or Gas

Water and Sewer

Telephone, cell phone, internet, cable

Trash

Security

Basic Needs

Food and housekeeping supplies

Childcare and children's education costs

Clothing

Laundry/Dry Cleaning

Personal Care products and services

Medical and dental expenses (not covered by insurance)

Transportation

Gasoline/auto maintenance

Other Expenses

Newspapers/Magazine subscriptions

Tithing (if claimed on taxes)

Insurance

Life (if not deducted from wages)

Health (if not deducted from wages)

Automobile Insurance

Other

Taxes

Ad Valorem (automobile)

Installment Payments

Auto

Auto 2

Auto 3

Rent to Own Contracts

Student Loan Repayment

Domestic Support Obligations

Alimony

Child Support

Other Living Expenses

Other

PLEASE ANSWER THE FOLLOWING QUESTIONS

Have you filed tax returns for the last 4 years?*

Yes
No

Do you have copies of these returns?

Do you normally get tax refunds larger than $1,500?

If you decide to file bankruptcy, you may have to forfeit future refunds while you
are in the case. Please ask the attorney if this affects you.

Have you lived in Georgia for the past 2 years?

What bank or banks/credit unions do you have a checking or savings account with?

What are the balances of each bank account?

Do you owe this bank any money for a loan?

Do you have any auto draft payments set up through this account?

Do you belong to a credit union?

If so, do you owe the credit union any money for a loan?

Are they deducting any money from your paycheck for a loan?

Are you buying or own a house or land of any kind?

If so, who is the mortgage company?

Do you belong to a Homeowner’s Association?

Do you any interest in a timeshare property?

Do you own any real estate with another family member or an ex-spouse?

Have you owned a house or any land of any type within the past 5 years?

Do you own, or are you a buying, a mobile home?

Do you have any Title Pawns?

List the year, make, model and mileage of ALL AUTOMOBILES in your name whether you are financing, just a co-signer, or own (even if it is on blocks in your front yard). Also list the co-signer next to the automobile if applicable. If none, please write none.

List the year and make of any boats, 4-wheelers, motorcycles, valuable tools, riding lawn mowers, or antiques with significant value whether you are financing or own:

List ALL electronics (including TVs, game consoles, DVD players, etc.):

Do you own any other valuable assets besides your house, cars, furniture, electronics, etc.?

How many people reside in your household?

List your dependents (relationship and ages):

Have you filed bankruptcy within the past 8 years? What year?

Do you pay or receive child support?*

Yes
No

If you pay child support list the name and address of the support holder:

Do you have any leases (including automobiles) or rent to own contracts, like Aarons Rental or Rent-A-Center? If so list the name of the company, what you are leasing, and the month and year the contract expires:

Are you currently suing anyone for money or damages?

Do you have any lawsuits (like personal injury, workers compensation, or any other claim for money) active or pending?

Do you plan on suing anyone for anything like the above?

Do you put money into a 401k or other retirement plan?

Are you currently paying back a loan against your 401(k) Plan? If so, list month and year you will be finished paying for it:

Have you taken out a loan or withdraw from your Retirement Plan within the last 7 months?

Do you own any stocks, bonds, or money market accounts?

Have you used any credit cards for cash advances or purchases totaling more than $1000 on any one card in the past 6 months? If so list which cards:

Have you made any balance transfers on credit cards in the past 6 months?

Have you paid any money to relatives in the past year for more than $1000?

Have you paid back any loan to relatives in the past year?

Have you had any losses like fire, theft, or car wrecks in the past year?

Have you had any repossessions or foreclosures in the past year?

Have you traded in any vehicles in the past year?

Have you sold or transferred any assets of yours into another person’s name within the past 5 years?

Have you ever operated under a business name or corporation in the past 6 years?

Are you expected to inherit property?

Do you expect to inherit property in the next 6 months?

Are you currently acting as an executor of an ongoing estate?

Does anyone owe you money for any reason?

Do you receive any other source of income besides your main job (for example, do you have a part-time job, do family members give you money, or do you receive any type of government assistance like Social Security or Food Stamps)?

CAPTCHA

Client Information

Spouse Information

PRIOR BANKRUPTCY CASES:

MONTHLY BUDGET

Housing Expenses

Utilities

Basic Needs

Transportation

Other Expenses

Insurance

Taxes

Installment Payments

Domestic Support Obligations

Other Living Expenses

PLEASE ANSWER THE FOLLOWING QUESTIONS

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