Client Intake Forms | Law Offices of Lauren Ross

01

General Information

Please fill out ALL information. Write "N/A" if a question does not apply to you.

First Name*

Middle Name (spell out)

Last Name*

Social Security Number

Date of Birth

Street Address

City

State

ZIP Code

County of Residence

Length of Time at This Address

Home Phone

Other Phone

Other Phone Type

Email Address*

Mailing Address — Leave blank if same as above

02

Information About Your Spouse

Spouse First Name

Spouse Middle Name (spell out)

Spouse Last Name

Spouse Social Security Number

Spouse Date of Birth

Spouse Street Address

City

State

ZIP Code

Spouse Home Phone

Spouse Other Phone

Other Phone Type

Spouse Email

Have you resided in the same county for at least 180 days (6 months)?

Yes No

If not, where have you resided?

Are you filing this bankruptcy petition with your spouse?

Yes No

If NOT filing with spouse, reason:

Unmarried Spouse filing separately Other reason

Have you EVER filed for bankruptcy?

Yes No

If yes, provide:

County Filed

Date(s) Filed

Case Number(s)

Chapter

03

Information for Means Test — Dependents

Means Test does NOT apply — Debtor(s) is a disabled veteran with debts incurred primarily during active duty or homeland defense.

List all dependents below.

04

Information for Means Test — 6-Month Income

Today's Date * — Required for Means Test calculation

Report GROSS income earned (before taxes). DO NOT deduct taxes. Include current month and the past five months (6 months total).

Wages, salaries, tips, bonuses, overtime and commissions

	Current Month	Last Month	2 Months Ago	3 Months Ago	4 Months Ago	5 Months Ago
INDIVIDUAL
SPOUSE

Income from operation of business, profession or farm

	Current Month	Last Month	2 Months Ago	3 Months Ago	4 Months Ago	5 Months Ago
INDIVIDUAL
SPOUSE

Rents and other property income (rents paid to you, not by you)

	Current Month	Last Month	2 Months Ago	3 Months Ago	4 Months Ago	5 Months Ago
INDIVIDUAL
SPOUSE

Interest income, dividends and royalties

	Current Month	Last Month	2 Months Ago	3 Months Ago	4 Months Ago	5 Months Ago
INDIVIDUAL
SPOUSE

Pension and retirement income

	Current Month	Last Month	2 Months Ago	3 Months Ago	4 Months Ago	5 Months Ago
INDIVIDUAL
SPOUSE

Income from others not filing bankruptcy who contribute to household expenses

	Current Month	Last Month	2 Months Ago	3 Months Ago	4 Months Ago	5 Months Ago
INDIVIDUAL
SPOUSE

Unemployment compensation

	Current Month	Last Month	2 Months Ago	3 Months Ago	4 Months Ago	5 Months Ago
INDIVIDUAL
SPOUSE

Income from State Disability

	Current Month	Last Month	2 Months Ago	3 Months Ago	4 Months Ago	5 Months Ago
INDIVIDUAL
SPOUSE

Income from other sources not listed above

	Current Month	Last Month	2 Months Ago	3 Months Ago	4 Months Ago	5 Months Ago
INDIVIDUAL
SPOUSE

Other Information

Have either you or your spouse been known by any other name during the past 8 years? (maiden name, previous marriage, legal name change)

Yes No

Name Used

Dates Used

Name Used

Dates Used

Has your income significantly increased or decreased during the past six months? If so, provide details:

05

Your Real Estate

Complete one set of fields for each property you own. Click "Add another property" if you own more than one.

07

Your Mobile Home

Complete only if you own a mobile home. Add another set of fields if you own more than one.

Name(s) on Title

Address of Mobile Home

Are the wheels completely removed and the mobile home attached to the ground?

Yes No

Does your mobile home sit in a mobile home park?

Yes No

Monthly Lot Rent

Does your mobile home sit on ground you own?

Yes No

Size of Ground

Do you make separate payments for the ground?

Yes No

If separate ground payments, explain:

If ground owned free and clear — resale value

Description of Mobile Home

Mortgage Information

Mortgage Company Name

Address

City

State

ZIP

Account Number

Date Obtained

Monthly Payment

Pay-Off Amount

Are you behind in payments?

Yes No

If behind, which months?

Interest Rate

Amount to Catch Up

Year Last Appraised

Appraised Value

Do you have a second mortgage?

Yes No

06

Your Household Inventory

Check items you own and provide the yard sale value — NOT replacement cost.

Other Assets

Rent Deposit with Landlord

Government Bonds

Certificate of Deposits

Copyrights / Patents

Aircraft

Interests in Education IRA

Customer Lists

Other Asset (1)

Other Asset (2)

Other Asset (3)

Landlord Name (for rent deposit)

Landlord Address

08

Your Motor Vehicles

Include cars, trucks, SUVs, motorcycles, mobile homes, boats, trailers, and campers titled in your or your spouse's name.

09

Your Debts

List EVERY debt you owe — including loans from relatives. Do not omit debts you want to keep. Spell out all company names completely.

10

Income History — You

Employment Information

Name as listed on paycheck stub

Year-to-Date Total (this year)

Gross Income Last Year

Gross Income 2 Years Ago

Employer Name

Employer Address

City

State

ZIP

Employer Telephone

Length of Time at This Job — Years

Months

Job Title (do not abbreviate)

How often are you paid?

Weekly Bi-weekly (every 2 weeks) Semi-monthly (same 2 days each month) Once a month

Average Gross Wages (before deductions)

Average Overtime / Commissions per Pay Period

Total Taxes Deducted per Paycheck (FICA, Federal, State, Local)

Insurance Deducted from Paycheck

Union Dues Deducted

Alimony or Child Support Paid

Are you court-ordered to pay this alimony/child support?

Yes No

Other Paycheck Deductions — Amount

What is this deduction for?

If 401(k) — how long have you participated?

Additional Monthly Income (business, flea market, etc.)

Other Monthly Income Sources

Monthly Rental Income

Monthly Interest and Dividends

Monthly Alimony / Child Support Received

Monthly Social Security

Monthly Government Assistance

Monthly Food Stamps

Monthly Public Assistance

Monthly Pension or Retirement

Other Income — reason and monthly amount

Second Job (if applicable)

Do you have a second job?

Yes No

Second Employer Name

Address

City

State

ZIP

Telephone

Length of Time at Second Job

Job Title

How often paid at second job?

Weekly Bi-weekly Semi-monthly Once a month

Average Gross Wages at Second Job

Do you receive income from a home-based business?

Yes No

Home Business Monthly Income

11

Income History — Your Spouse

Employment Information

Name as listed on paycheck stub

Year-to-Date Total (this year)

Gross Income Last Year

Gross Income 2 Years Ago

Employer Name

Employer Address

City

State

ZIP

Employer Telephone

Length of Time at This Job — Years

Months

Job Title (do not abbreviate)

How often are you paid?

Weekly Bi-weekly (every 2 weeks) Semi-monthly (same 2 days each month) Once a month

Average Gross Wages (before deductions)

Average Overtime / Commissions per Pay Period

Total Taxes Deducted per Paycheck (FICA, Federal, State, Local)

Insurance Deducted from Paycheck

Union Dues Deducted

Alimony or Child Support Paid

Are you court-ordered to pay this alimony/child support?

Yes No

Other Paycheck Deductions — Amount

What is this deduction for?

If 401(k) — how long have you participated?

Additional Monthly Income (business, flea market, etc.)

Other Monthly Income Sources

Monthly Rental Income

Monthly Interest and Dividends

Monthly Alimony / Child Support Received

Monthly Social Security

Monthly Government Assistance

Monthly Food Stamps

Monthly Public Assistance

Monthly Pension or Retirement

Other Income — reason and monthly amount

Second Job (if applicable)

Do you have a second job?

Yes No

Second Employer Name

Address

City

State

ZIP

Telephone

Length of Time at Second Job

Job Title

How often paid at second job?

Weekly Bi-weekly Semi-monthly Once a month

Average Gross Wages at Second Job

Do you receive income from a home-based business?

Yes No

Home Business Monthly Income

12

Self-Employed Business Owners

Complete only if you have been self-employed during the past 12 months.

Average Monthly Business Income

Did you withhold earnings for tax purposes?

Yes No

Amount Withheld Monthly

Average Monthly Business Expenses

Rent and Utilities

Office Supplies

Product Supplies

Wages

Equipment Leases

Other Business Leases

Other Expenses (1)

Other Expenses (2)

Other Expenses (3)

Total Average Monthly Income

Total Average Monthly Expenses

Average Monthly Business Profit

Did you file income taxes for all years you operated this business?

Yes No

If not, which years did you NOT file?

13

Monthly Budget

Enter MONTHLY amounts. For utilities, use an average covering the full 12 months.

Housing

Rent (if you do not own your home)

First Mortgage / Mobile Home Payment

Second Mortgage

Third Mortgage

Lot Payment

Property Taxes (if NOT in mortgage)

Home Insurance (if NOT in mortgage)

Are real estate taxes included in your mortgage payment?

Yes No

Is home insurance included in your mortgage payment?

Yes No

Utilities

Electricity and Gas

Water

Telephone (basic service)

Trash Pick-Up

Basic Needs & Transportation

Home Maintenance

Food

Clothing

Laundry / Dry Cleaning / Soap

Medical Expenses Not Paid by Insurance

Gasoline / Auto Maintenance

Recreation / Entertainment

Charitable Giving (if claimed on taxes)

Insurance

Renters Insurance

Life Insurance (other than employer)

Health Insurance (other than employer)

Automobile Insurance

Other Insurance

Other Expenses

Alimony or Child Support

Payments for Someone Outside Your Home

Union Dues (not payroll deducted)

Professional Dues

Child Care / Babysitter / Day Care

School Expenses

School Lunch

College Tuition (not loans)

Student Loan Repayment

Newspapers / Books / Magazines

Personal Care Items

Other Taxes (describe)

Other (1)

Other (2)

Describe any additional monthly expenses not covered above:

14

Statement of Affairs

The Trustee will ask you many of these questions again at your first hearing. Answer every question. If yes, fill in all requested details.

Previous Spouses & Other Interests

Previous Spouses

Spouse 1 — Full Name

Dates Married

Spouse 2 — Full Name

Dates Married

Spouse 3 — Full Name

Dates Married

Spouse 4 — Full Name

Dates Married

Have you ever provided notice to any governmental unit of a release of hazardous materials?

Yes No

Name/Address of Site

Governmental Unit Notice Sent To

Date Notice Sent

Do you share ownership of any real property with another person (co-tenancy or joint tenancy, not spouse)?

Yes No

Name of Co-Owner

Do you have a future interest in any real estate (e.g., money down on a property not yet purchased)?

Yes No

If yes, provide details:

Do you own or are you buying a time-share in a vacation property or resort?

Yes No

If yes, provide details:

Do you have a car, truck, motorcycle, boat or camper in your possession titled in someone else's name?

Yes No

Year, Make, Model

Whose name is it titled to?

Their Address

City / State / ZIP

Relationship to You

Why are you holding this property?

Personal Property Obligations

Are you buying any furniture or appliances on installment payments?

Yes No

Are you renting-to-own any furniture or appliances?

Yes No

Have you listed any furniture, appliances or possessions as collateral to obtain a loan?

Yes No

Furniture / Appliances on Installment or as Collateral

Item 1 — Description

Yard Sale Value

Item 2 — Description

Yard Sale Value

Item 3 — Description

Yard Sale Value

Company You Make Payments To

Do you own or are you buying tools or equipment that you use for your work?

Yes No

Description of Work Tools / Equipment

Yard Sale Value of Tools

Who do you make payments to (if applicable)?

Do you have any inventory (stock in trade) that could be sold for $200 or more in profit?

Yes No

Description

Value

Jewelry, Animals & Bank Accounts

Are you buying any jewelry on installment payments?

Yes No

Jewelry Item 1

Value

Jewelry Item 2

Value

Company You Make Payments To

Do you have any animals, livestock, or pets you could sell for $200 or more?

Yes No

Description of Animals

Value if Sold

Do you have any checking or savings accounts?

Yes No

Bank Account 1

Bank Name

Branch Address

City

State

ZIP

Account Type

Name(s) on Account

Checking Account Number

Balance

Savings Account Number

Balance

Bank Account 2 (if applicable)

Bank Name

Branch Address

City

State

ZIP

Account Type

Name(s) on Account

Account Number

Balance

Have you closed any bank accounts within the past two years?

Yes No

Bank Name

Address

City

State

ZIP

Account Number

Date Closed

Name on Account

Did you owe a balance when you closed this account?

Yes No

Balance Owed (if yes)

Money Received (if no balance owed)

Safe Deposit, Insurance & Retirement

Do you rent or have you rented a safe deposit box in the past two years?

Yes No

Financial Institution

Address

City

State

ZIP

Contents of Safe Deposit Box

Monthly Rental Amount

If surrendered — date surrendered

If transferred — transferred to whom?

Do you have a Christmas Club or other special purpose savings account?

Yes No

Financial Institution

Account Type

Account Number

Name(s) on Account

Present Balance

Do you currently have any security deposits held by a utility company?

Yes No

Utility Company Name

Address

City

State

ZIP

Account Number

Deposit Balance

Do you have any life insurance?

Yes No

Insurance Company Name

Cash Value (whole life policy)

Face Value (death benefit)

Beneficiary

Beneficiary Relationship

Do you or your spouse participate in a retirement, 401(k), or pension plan?

Yes No

Type of Plan (401-K, PERS, etc.)

Date First Enrolled

Current Cash Value

Stocks, Cell Phone & Household Support

Have you set up your own retirement not provided by employer?

Yes No

Financial Institution

Amount in Account

Beneficiary

Will you be receiving retirement benefits from a previous employer within the next six months?

Yes No

Expected Start Date

Do you have any stocks, bonds (including savings bonds), or mutual funds?

Yes No

Type of Stock / Bond / Mutual Fund

Cash Value

Do you have a cell phone?

Yes No

Cell Phone Company

Address

City

State

ZIP

Account Number

Date Contract Began

Contract Length

Monthly Contract Payment

Do you wish to keep the cell phone and continue paying?

Yes No

Do you live with a roommate or relative who pays part of your expenses?

Yes No

Name of Roommate / Relative

Relationship

What expenses do they pay?

Total Monthly Contribution

How long? From

To

Do relatives or other parties help pay part or all of your monthly expenses?

Yes No

Name of Relative(s)

Relationship

Total Monthly Contribution

How long? From

To

College, Fines & Child Support

Are you currently attending college?

Yes No

College Name

Anticipated Graduation Date

Major of Study

Do you have a student loan?

Yes No

Institution You Make Payments To

Address

City

State

ZIP

Date Loan First Obtained

Date Payment Begins/Began

Total Pay-Off Amount

Average Monthly Payment

Do you currently owe any fines (parking tickets, moving violations, etc.)?

Yes No

Court You Owe Fines To

Court Address

City

State

ZIP

Date of Occurrence

Amount Owed

Case Number

Party Responsible

Husband Wife Other

What was this fine for?

If you pay child support — are you currently behind in any payments?

Yes No

Name of Person/Agency You Pay

Address

City

State

ZIP

Total Amount in Back Child Support

Date Support Was Supposed to Start

Payment Arrangements

Does an ex-spouse owe you money for alimony or child support?

Yes No

Ex-Spouse Name

Ex-Spouse Address

City

State

ZIP

Total Amount Owed to You

Date They Started Owing You

Year of Court Order

Accidents, Inheritances, Claims & Property Held

Over the last year, have you, your children, or your spouse been involved in an accident where someone was hurt?

Yes No

Date of Accident

Who Was at Fault?

Who Was Involved?

Was insurance money received?

Yes No

Insurance Amount Received

During the next six months, do you expect to inherit anything?

Yes No

Expected Amount

Expected Date

Reason for Inheritance

Do you expect to recover on anyone's life insurance policy in the next six months?

Yes No

Expected Amount

Expected Date

Reason

Do you expect to receive money from any insurance claim in the next six months?

Yes No

Expected Amount

Expected Date

Reason

Are you the beneficiary of a trust fund?

Yes No

Amount of Trust Fund

Trust Fund Owner Name

Relationship to You

When Will You Have Access?

Are you owed back wages, commissions, or vacation pay from a current or previous employer?

Yes No

Employer Name

Amount Expected

Date Expected

Details

Is any of your property in the hands of a repairman, storage company, or pawnbroker?

Yes No

Name of Place Holding Your Property

Address

City

State

ZIP

Description of Items and Yard Sale Values

Total Amount to Pay to Get Items Released

Lawsuits, Garnishments, Gifts & Transfers

In the near future, do you expect to settle, win, or begin a personal injury case?

Yes No

Expected Amount

Expected Date

Details of Claim

Attorney / Law Firm Handling Claim

Do you expect to enter into a property settlement with a former spouse?

Yes No

Items Expected to Receive or Turn Over (including cash)

Total Market Value of Items

When Do You Expect to Receive/Turn Over?

Does anyone owe you money from a judgment you obtained against them?

Yes No

Name of Party You Filed Lawsuit Against

Address

City

State

ZIP

Date Lawsuit Filed

Money Amount Awarded

Does anyone owe you money for any reason (even if you never expect to collect)?

Yes No

Name of Person Who Owes You

Address

City

State

ZIP

Explain Why They Owe You Money

Amount Owed

Date They Started Owing You

Have you made any payments on loans or bills other than ordinary payments? (catch-up payments, payoffs, borrowed to pay off bills)

Yes No

Unusual Payments

Creditor Name (1)

Date Paid

Amount Paid

Current Balance Due

Creditor Name (2)

Date Paid

Amount Paid

Current Balance Due

Losses, Prior Attorneys, Prior Bankruptcy & Previous Addresses

Are there any lawsuits pending against you now?

Yes No

Name of Party Suing You (Plaintiff)

Case Number

Date Lawsuit Filed

Type of Lawsuit (from court pleading)

Plaintiff's Attorney Name

Attorney Address

City

State

ZIP

Court Where Filed

Court Address

City

State

ZIP

Have your wages or property been garnished or attached?

Yes No

Who Garnished Your Wages / Attached Property?

What Did They Repossess?

How Much Is Taken from Your Paycheck?

How Often Is This Deducted?

Have you returned property to creditors, or was any property repossessed, sold at foreclosure, or transferred through a deed?

Yes No

What property was involved and when/where?

Is any of your property in receivership or other legal custody?

Yes No

Date of Receivership Filing

Court Where Filed

Have you made any gifts to friends or relatives?

Yes No

Description of Gift(s)

Who Did You Give the Gift To?

Date/Year

Approximate Value

Have you transferred money or property to family members or friends, or paid them money on debts you owe them?

Yes No

Type of Property Transferred

Date/Year Transferred

Approximate Value

Business History, Other Income & Tax Refund

Have you had any unusual losses such as fire, theft, or gambling?

Yes No

Type of Loss:

Fire Theft Gambling Other

Items or Money Lost

Date/Year of Loss

Amount Insurance Paid

Have you had any losses covered by insurance?

Yes No

Describe Loss

Date/Year of Loss

Amount Insurance Paid

Have you consulted any other attorney about your finances, or paid a debt counseling service?

Yes No

Attorney or Service Name

Address

City

State

ZIP

Consultation Date

Total Paid for Service

Have you filed any bankruptcy within the last eight years?

Yes No

Is anyone holding any property that belongs to you?

Yes No

Items in Someone Else's Possession

Name of Person Holding Items

Address

City

State

ZIP

Previous Addresses (past 6 years)

Previous Address 1

City

State

ZIP

From (date/year)

To (date/year)

Name(s) of Parties Who Lived There

Previous Address 2

City

State

ZIP

From (date/year)

To (date/year)

Name(s) of Parties Who Lived There

Previous Address 3

City

State

ZIP

From (date/year)

To (date/year)

Name(s) of Parties Who Lived There

Previous Address 4

City

State

ZIP

From (date/year)

To (date/year)

Name(s) of Parties Who Lived There

Previous Address 5

City

State

ZIP

From (date/year)

To (date/year)

Name(s) of Parties Who Lived There

Have you been self-employed or had any financial interest in any business within the past eight years?

Yes No

Business Name

Business Address

Type of Business / Products Sold

Date Business Began

Date Business Ended

Names of Partners / Co-Investors / Associates

Net Profits This Year

Net Profits Last Year

Net Profits 2 Years Ago

Income Tax Paid on Business Income

During the past two years, have either you or your spouse had any income source outside normal employer pay?

Yes No

Income This Year

Income Last Year

Income 2 Years Ago

Tax Refund

Amount of Tax Refund Received This Year

I did not file taxes I had to pay taxes and did not receive a refund

15

Certification & Signature

By submitting this form, I state that all information provided in these Client Intake Forms is true, accurate and complete to the best of my knowledge.

Printed Name — Debtor #1*

Date*

Printed Name — Debtor #2 (if applicable)

Date

Complete your intake forms
before your appointment.

General Information

Information About Your Spouse

Information for Means Test — Dependents

Information for Means Test — 6-Month Income

Your Real Estate

Your Mobile Home

Your Household Inventory

Your Motor Vehicles

Your Debts

Income History — You

Income History — Your Spouse

Self-Employed Business Owners

Monthly Budget

Statement of Affairs

Certification & Signature

Submit Your Intake Forms

Forms Received — Thank You

Complete your intake formsbefore your appointment.

General Information

Information About Your Spouse

Information for Means Test — Dependents

Information for Means Test — 6-Month Income

Your Real Estate

Your Mobile Home

Your Household Inventory

Your Motor Vehicles

Your Debts

Income History — You

Income History — Your Spouse

Self-Employed Business Owners

Monthly Budget

Statement of Affairs

Certification & Signature

Submit Your Intake Forms

Forms Received — Thank You

Complete your intake forms
before your appointment.