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Bankruptcy Intake Form

Name:

First	M.I.	Last

Spouse Name:

First	M.I.	Last

Address:

Street	City	State	Zip

Length at address:
	Do you own?	yes no

Phone:

Home	Work	Alternate

Email:

Your Email

Marital Status:

Employer:

Occupation:

Dates of Employment:

Salary:
$0-$29,000.00 $30,000.00- $44,000.00 $45,000.00- $59,000.00 $60,000.00- $74,000.00 $75,000.00- ABOVE

1.	Have you co-signed on a loan for anyone else?	yes no

2.	Do you have anything of yours in the possession or name of someone else?	yes no

3.	Do you have your name on anyone else’s bank account, real property or vehicle?	yes no

4.	Are you suing any one or have the right to sue them?	yes no

5.	Have you filed for Bankruptcy within the last 8 years?	yes no

6.	Have you sold, transferred or closed any business (or an interest in) with in the past three years?	yes no

7.	Have you paid any family member any money in the past year (excluding support)?	yes no

8.	Have you filed all tax returns for the past three years?	yes no

9.	Have you made any major purchases (over $200) on any credit card in the past three months?	yes no

10.	Have you taken any cash advances in the past three months?	yes no

11.	Have you made any balance transfers on any credit card in the past three months?	yes no

12.	Do you own any money from a marital settlement or judgment of divorce?	yes no

13.	Have you been ordered to pay child or spousal support?	yes no

14.	Is any support pat due?	yes no

15.	Does any one owe you money for any reason?	yes no

16.	Do you have any claims against any one or the right to sue any one?	yes no

17.	Do you have any tax refund due you at this time?	yes no

18.	Have you changed any payroll deduction with in the past six months?	yes no

19.	Have you set up a trust in the past ten years?	yes no

20.	Do you receive any income from a trust or annuity?	yes no

21.	Do you have income from royalties, gas or mineral rights, copyrights, licenses agreements or patents now or in the future?	yes no

22.	Do you have a life estate or the right to use anyone else’s property?	yes no

23.	Have you given away, traded or transferred anything worth more then $1,000 in the past five years.	yes no
23a.	If so, specify the dates, property description, value and to whom it was given:

24.	Do you have a storage unit?	yes no
24a.	If so, what is in it:

25.	Do you have a safety deposit box?	yes no
25a.	If so, what is in it:

26.	Any thing else you think the attorney should be made aware of?	yes no

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Haines & Krieger, L.L.C. 1020 Garces Ave., Suite 100, Las Vegas, Nevada 89101 | phone: 702-880-5554, fax: 702-385-5518
email: info@hainesandkrieger.com