Intake Form


DOAN LAW FIRM BANKRUPTCY INTAKE SHEET

Complete this Bankruptcy Intake Sheet to the best of your ability and we can immediately let you know whether you qualify to file Chapter 7 or Chapter 13 Bankruptcy Relief. Upon submission, it will be reviewed by an attorney, not a paralegal, who will assess your case and let you know whether or not you qualify to file. All information submitted is confidential and is fully protected by the attorney-client privilege. If you qualify to file, you would STOP paying your creditors immediately and we would start representing you with as little as $100.00 down.

Date

Have you Consulted for Bankruptcy Before?

Filed Bankruptcy Before?

How did you hear about us?
InternetReferralPennysaverPhonebookYelpOther

WE FILE 2 TYPES OF CONSUMER BANKRUPTCIES: Which do you prefer?
Ch 7 - Remove debt forever!Ch 13 - Consolidate & Repay debt over 3-5 years

A. PERSONAL INFORMATION

First Name

Middle Name

Last Name

Street Address (Residence)

City

Zip Code

Have you lived in California for the last 2 years?
YesNo

If not California, where did you live 2 years ago?

Day Phone

Work Phone

Cell Phone

Age

Marital Status
SingleMarriedDivorcedSeparatedWidowed

Number of Dependents

SPOUSE'S INFORMATION

First Name

Middle Name

Last Name

Street Address (Residence)

City

Zip Code

Have you lived in California for the last 2 years?
YesNo

If not California, where did you live 2 years ago?

Email

Day Phone

Work Phone

Cell Phone

Social Security Number

Age

Marital Status
SingleMarriedDivorcedSeparatedWidowed

Number of Dependents

B. DO YOU OR YOUR SPOUSE OWN ANY REAL ESTATE? NoYes
( if No, skip to C. )

Description
(Home, Condo, etc. )
Present Value Value Based Upon? (appraisal/comps/etc) Year Purchased Purchase Price

$

$

Estimate if unknown Balance Owed Monthly Payment Interest Rate # Months Late Reinstatement Amount (Arrears)
First Mortgage

$

$

Second Mortgage

$

$

Other Liens

$

$

Have you filed a Homestead Declaration?
NoYesDon't Know

Have you received a "Notice of Default"?
NoYes
When?

Is there a Sale Date Pending?
NoYes
When?

C. CAR/MOTORCYCLE INFORMATION – Give your best estimates. List all cars, whether PAID OR NOT, IN YOUR NAME OR NOT.

Year Auto Make Auto Model Mileage Mo/Yr Bought Fair Market Value Loan Name of Lien Holder Balance Owed Monthly Payment # Mo's Late

PurchaseLease

PurchaseLease

PurchaseLease

D. OTHER DEBT INFORMATION – Give your best estimates

Please Give Your Best Estimates Approx # of Items Approx Total Combined Balances Approx Total Charges within last 6 Months Approx Total Payments within last 6 Months Months Late
1. Credit Cards (i.e. Visa, MC, AMEX, Discover )

2. Medical Bills

3. Personal Loans (i.e. Credit Union, Family, Friends)

4. Repossessions

5. Student Loans

6. Support Obligations

7. Taxes

8. Traffic Fines or Restitution

  Totals:

E. RETIREMENT, 401K, IRA, EDUCATIONAL IRA, STOCK, BANK ACCOUNTS & OTHER VALUABLE ASSETS – Give your best estimates.

Retirement Plan (i.e. 401K, IRA, PERS, Profit Sharing)

Vested Value
$

Loans Taken Against It
$

Monthly Contribution You Make
$

Bank/Savings Accounts
$

Stocks
$

Cash value of life insurance
$

Other valuable assets worth > $300
$

F. EMPLOYMENT & INCOME INFORMATION – Please estimate you and your spouse’s GROSS INCOME (income before taxes & deductions)

Current Occupation

Last year gross income
$

Hours work each week

Hourly Rate
$ /hour

Total Past 6 Months Income
$

Current Monthly Gross
$

Spouse's Current Occupation

Last year gross income
$

Hours work each week

Hourly Rate
$ /hour

Total Past 6 Months Income
$

Current Monthly Gross
$

G. Monthly Living Expenses IF NO DEBT – Give your best estimates

Monthly Expense Estimate
Rent/Total Mortgage Payments $
Gas & Electricity $
Water & Sewage $
Phone $
Cable/Satellite/Internet $
Home Maintenance $
Food $
Clothing/Laundry/Dry Cleaning $
Out-of-pocket medical & dental expenses $
Transportation/Gas $
Recreation, entertainment, magazines $
Charitable Contributions $
Insurance - Homeowner's/Renter's $
Insurance - Medical/Dental/Eye (out of pocket) $
Insurance - Auto $
Car Payments $
PAST Taxes (not already deducted from pay) $
Childcare/Daycare $
Spousal/Child Support (court ordered) $
Support -other (not court ordered) $
Business Expenses/Tools of Trade $
Student Loan Payments $
Storage $
Pets $
Gardener $
Gym,Parking,Bank Fees $
Auto Upkeep $
Fines/Tickets $
School/Books/Education for Trade $
TOTAL (Automatically added) $

Do you have or expect to receive any income or property from the following:

Royalties?
YesNo

Trust Fund?
YesNo

Inheretance?
YesNo

Second Job?
YesNo

Life Insurance?
YesNo

MSA or Divorce?
YesNo

Overtime/Commissions?
YesNo

If Yes, please explain:

Have you transferred/sold assets > $1000 in last 2 years?
YesNo
Please explain:

Are you expecting a tax refund this year?
YesNo
Please explain:

Are there any co-signers on any of your accounts?
YesNo
Please explain:

Are you suing anyone? (i.e. Work Comp, MVA, etc)?
YesNo
Please explain:

Has any of the following occurred in the past 90 DAYS?

  1. $600 or more of wages garnished?
  2. $600 or more of bank account money taken?
  3. Judgment lien entered against you or lien on home?

If you answered yes on any of the above, please explain (who/how much/when):

Please check mark any other legal areas that may apply to you:


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Mike Doan - San Diego Bankruptcy Attorney, Southern California Phone: 800-380-3626

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