Bankruptcy Intake Form

Date:

Name:

Spouse Name:

Physical Address:

City:

State:

Zip Code:

Mailing Address:

City:

State:

Zip Code:

Email Address:

Spouse Email Address:

Home Phone:

Work Phone:

OK TO CALL WORK? Yes No

Employer:

Occupation:

Client Cell Phone:

Spouse Cell Phone:

Client Age:

Client DOB:

Sex: Male Female

US Citizen: Yes No

Spouse Age:

Spouse DOB:

Sex: Male Female

US Citizen: Yes No

Client Driver’s License No.:

Spouse Driver’s License No.:

Client SSN (Last 4).:

Spouse SSN (Last 4).:

Names and Ages of Immediate Family Members (Living in your home)

Contact Person (A person that doesn’t live with you and would know how to locate you)

Name:

Address:

Phone No:

Relationship:

SUMMARIZE YOUR LEGAL PROBLEM IN YOUR OWN WORDS:

In order for the Attorney to gain general background information about your situation and to provide you with the best advice possible, please provide the following information. Your information is kept confidential. You may estimate information if you do not know at this time.

Do you own your home?................................................................................................. YES NO

If Yes, what is the current market value?

Pay Off Balance for 1st Mortgage:

Monthly Payment:

Pay Off Balance for 2nd Mortgage:

Monthly Payment:

Are the payments current?................................................................................................. YES NO

Past Due Amount:

Do you own any other real estate?................................................................................................. YES NO

Do you expect to acquire any other real estate in the near future?................................................................................................. YES NO

List the following information about your vehicles:

#	YEAR	MAKE	MODEL	MONTH/YEAR PURCHASED	VALUE	APPROX. PAY OFF BALANCE
1
2
3
4
5

How much is your current gross (before deductions) monthly income?

How much is your spouse/partner/co-habitant’s current gross monthly income?

Has your household income changed in the last 6 months?................................................................................................. YES NO

Do you expect your income to change in the next year?................................................................................................. YES NO

Are all of your taxes filed?................................................................................................. YES NO

If not, what tax years are due?

Do you owe any income tax?................................................................................................. YES NO

Provide the following information for any tax return filed within the last 3 years:

#	TAX YEAR	APPROX. DATE FILED	AMOUNT DUE
1
2
3

Do you normally receive a tax return when you file your tax return?....................................................... YES NO

If yes, how much is typical?

Do you owe any past due child/spousal support....................................................... YES NO

Have you ever filed a bankruptcy case before?....................................................... YES NO

If yes, what year did you file?

Previous Case No.:

Have you even been sued? ....................................................... YES NO

Are you owed any money for any reason?....................................................... YES NO

Are you aware of any right you may have to sue or make a claim against anyone? YES NO

Are you owed any money from any estate, trust or life insurance policy? ......... YES NO

Have you charged more than $1,000.00 on any credit cards in the last 6 months?.... ..... YES NO

Have you sold, gifted, or otherwise transferred anything of value to anyone within the last 12 months YES NO

How many dependents can you claim on your income tax return?

Do you own a boat?.......................................................................................................... YES NO

If yes, how much is it worth?

Do you own an RV/ Travel Trailer?............................................................................... YES NO

If yes, how much is it worth?

Do you own any motorcycles?.......................................................................................... YES NO

If yes, how much is it worth?

Do you have anything else of value?..................................................................……… YES NO

Describe:

How much do is it worth?

How much do you owe on it?

The following debts should NOT include any debts you have already listed

What is the approximate total balance you owe on credit cards?

What is the approximate total balance you owe on medical bills?

What is the approximate total balance you owe on other debts?

DEBT RELIEF AGENY DISCLOSURES UNDER SECTION 527 (a)

The bankruptcy laws require that you be giving the following disclosures:

The written notice required under section 342 (b)(1); and
To the extent not covered in the written notice described in paragraph (1), and not later than three
business days after the first date on which a debt relief agency first offers to provide any bankruptcy assistance services to an assisted person, a clear and conspicuous written notice advising assisted persons that—
1. All information that the assisted person is required to provide with a petition and thereafter during a case under this title is required to be complete, accurate, and truthful;
2. All assets and all liabilities are required to be completely and accurately disclosed in the documents filed to commence the case, and the replacement value of each asset as defined in section 506 must be stated in those documents where requested after reasonable inquiry to establish such value
3. Current monthly income, the amounts specified in section 707(b)(2) and, in a case under Chapter 13 of this title, disposable income (determined in accordance with Section 707(b)(2)), are required to be stated under reasonable inquiry; and
4. Information that as assisted person provides during their case may be audited pursuant to this title, and that failure to provide such information may result in dismissal of the case under this title or other sanction, including a criminal sanction

DATED:

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DEBT RELIEF AGENCY DISCLOSURES UNDER SECTION 527(b)

IMPORTANT INFORMATION ABOUT BANKRUPTCY ASSISTANCE SERVICES FROM AN ATTORNEY OR BANKRUPTCY PETITION PREPARER.

If you decide to seek bankruptcy relief, you can represent yourself, you can hire an attorney to represent you, or you can get help in some localities from a bankruptcy petition preparer who is not an attorney. THE LAW REQUIRES AN ATTORNEY OR BANKRUPTCY PETITION PREPAREER TO GIVE YOU A WRITTEN CONTRACT SPECIFYING WHAT THE ATTORNEY OR BANKRUPTCY PETITION PREPARER WILL DO FOR YOU AND HOW MUCH IT WILL COST. Ask to see the contract before you hire anyone.

The following information helps you understand what must be done in a routine bankruptcy case to help you evaluate how much service you need. Although bankruptcy can be complex, many cases are routine.Before filing a bankruptcy case, either you or your attorney should analyze your eligibility for different forms of debt relief available under the Bankruptcy Code and which form of relief is most likely to be beneficial for you. Be sure you understand the relief you can obtain and its limitation. To file a bankruptcy case, documents called a Petition, Schedules and Statement of Financial Affairs, as well as in some cases a Statement of Intention needs to be prepared correctly and filed with the bankruptcy court. You must pay a filing fee to the bankruptcy court. Once your case starts, you will have to attend the required first meeting of creditors where you may be questioned by a court official called a ‘trustee’ and by creditors.

If you chose to file a Chapter 7 case, you may be asked by a creditor to reaffirm a debt. You may want help deciding where to do so. A creditor is not permitted to coerce you into reaffirming your debts.

If you choose to file a Chapter 13 case, in which you can repay your creditors what you can afford over the next 3 to 5 years. You may want help with preparing your Chapter 13 Plan and with the confirmation hearing on your plan which will be before a bankruptcy judge.

If you select another type of relief under the Bankruptcy Code other than a Chapter 7 or Chapter 13, you will want to find out what should be done from someone familiar with that type of relief.

Your bankruptcy case may also involve litigation. You are generally permitted to represent yourself in litigation in bankruptcy court, but only Attorneys, not bankruptcy petition preparers, can give you legal advice.

The undersigned acknowledges receipt of this disclosure.

DATED:

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UNITED STATES BANKRUPTCY COURT
EASTERN DISTRICT OF CALIFORNIA

NOTICE TO CONSUMER DEBTOR(S) UNDER § 342 (b) OF THE BANKRUPTCY CODE

In accordance with § 342(b) of the Bankruptcy Code, this notice;

Described briefly the services available from credit counseling services
Describes briefly the purposes, benefits and costs of the four (4) types of bankruptcy proceedings you may commence
Informs you about bankruptcy crimes and notifies you that the Attorney General may examine all information you supply in connection with a bankruptcy case.

You are cautioned that bankruptcy law is complicated and not easily described. Thus, you may wish to seek the advice of at Attorney to learn of your rights and responsibilities should you decide to file a petition. Court employees cannot give you legal advice.

Notices from the Bankruptcy Court are sent to the mailing address you list on your bankruptcy petition. In order to ensure that you receive information about events concerning your case, Bankruptcy Rule 4002 requires that you notify the court of any changes in your address. If you are filing a joint case (a single bankruptcy case for two people married to each other), and each spouse lists to same mailing address on the bankruptcy petition, you and your spouse will general receive a single copy of each notice mailed from the bankruptcy court in a jointly-addressed envelope, unless you file a statement with the court requesting that each spouse receive a separate copy of all notices.

1. SERVICES AVAILABLE FROM CREDIT COUNSELING AGENCIES

With limited exceptions, § 109(h) of the Bankruptcy Code requires that all individuals who file for bankruptcy relief on or after October 17, 2005, receive a briefing that outlines the available opportunities for credit counseling and provides assistance in performing a budget analysis. The briefing must be given within 180 days before the bankruptcy filing. The briefing may be provided individually or in a group (including briefings conducted by telephone or on the internet) and must be provided by a nonprofit budget and credit counseling agencies that you may consult is posted by the United States Trustee Programs website at www.usdoj.gov/ust. If is also available in the bankruptcy clerk’s office. Each debtor in a joint case must complete the briefing.

In addition, after filing a bankruptcy case, an individual debtor generally must complete a financial management instructional course before he or she can receive a discharge. A list of approved financial management instructional courses is also available on the United States Trustee Program’s website www.usdoj.gov/ust and the bankruptcy clerk’s office. Each debtor in a joint case must complete the course.

2. THE 4 CHAPTERS OF THE BANKRUPTCY CODE AVALIABLE TO INDIVIDUAL COMSUMER DEBTORS

A. CHAPTER 7: LIQUIDATION

Chapter 7 Bankruptcy is designed for debtors in financial difficulty who do not have the ability to pay their existing debts. Debtors whose debts are primarily consumer debts are subject to a “means test” designed to determine whether the case should be permitted to proceed under Chapter 7. If your income is greater than the median income for your state of residence and family size, creditors have the right to file a motion requesting that the court dismiss your case under § 707(b) of the Bankruptcy Code. It is up to the court to decide whether the case should be dismissed. Under Chapter 7, you may claim certain amount of your property as exempt under governing law. A Trustee may have the right to take possession of and sell the remaining property that is not exempt and uses the sale proceeds to pay your creditors. The purpose of filing a Chapter 7 case is to obtain a discharge of your existing debts. If, however, you are found to have committed certain kinds of improper conduct described in the Bankruptcy Code, the court may deny your discharge and, if it does, the purpose for which you filed the Bankruptcy Petition will be defeated.

Even if you receive a general discharge, some particular debts are not discharged under the law. Therefore, you may still be responsible for most taxes and student loans; debts incurred to pay nondischargable taxes; domestic support and property settlement obligations, most fines, penalties, forfeitures, and criminal restitution obligations; certain debts whish are not properly listed in your bankruptcy papers; and debts or death or personal injury caused by operating a motor vehicle, vessel, or aircraft while intoxicated from alcohol or drugs. Also, if a creditor can prove that a debt arose from fraud, breach of fiduciary duty, theft or from a willful and malicious injury, the bankruptcy court may determine that the debt is not discharged.

B. CHAPTER 13: REPAYMENT OF THE DEBTS OF AN INDIVIDUAL WITH REGULAR INCOME

Chapter 13 Bankruptcy is designed for individuals with regular income who would like to pay all of part of their debts in installments over a period of time. You are only eligible for Chapter 13 if your debts do not exceed certain dollar amounts set forth in the Bankruptcy Code.

Under Chapter 13, you must file with the court a plan to repay your creditors all of part of the money that you owe them, using your future earnings. The period allowed by the court to repay your debts may be 3 to 5 years, depending upon your income and other factors. The court must approve your plan before it can take effect.

After completing the payments under your plan, your debts are generally discharged except for domestic support obligations; most student loans; certain taxes; most criminal fines and restitution obligations, certain debts which are not properly listed in your bankruptcy papers; certain debts for acts that caused death or personal injury, and certain long term secured obligations.

C. CHAPTER 11: REORGANIZATION

Chapter 11 Bankruptcy is designed for the reorganization of a business but is also available to consumer debtors. Its provisions are quite complicated, and any decision by and individual to file a Chapter 11 Petition should be reviewed with an attorney.

D. CHAPTER 12: FAMILY FARMER OR FISHERMAN

Chapter 12 Bankruptcy is designed to permit family farmers and fishermen to repay their debts over a period of time from future earnings and is similar to Chapter 13. The eligibility requirements are restrictive, limiting its use to those whose income arises primarily from a family-owned fishing operation.

3. BANKRUPTCY CRIMES AND AVAILABLILTY OF BANKRUPTCY PAPERS TO LAW ENFORCEMENT OFFICIALS

A person who knowingly and fraudulently conceals assets or makes a false oath or statement under penalty of perjury, either orally or in writing in connection with a bankruptcy case is subject to fine, imprisonment, or both. All information supplied by a debtor in connection with a bankruptcy case is subject to examination by the Attorney General acting through the Office of the United States Trustee, the Office of the United States Attorney, and other components and employees of the Department of Justice.

WARNING: Section 521(a)(1) of the Bankruptcy Code requires that you promptly file detailed information regarding your creditors, assets, liabilities, income, expenses and general financial condition. Your bankruptcy case may be dismissed is this information is not filed with the court within the time deadlines set by the Bankruptcy Code, the Bankruptcy Rules and the local rules of the court. The documents and deadlines are listed on Form ECD2-035, Required Documents and Fees, which is posted on the court website www.caeb.uscourts.gov.

I/We, the debtor(s), affirm that I/We have received and read the attached notice, as required by § 342(b) Bankruptcy Code

DATED:

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Bankruptcy Intake Form

SUMMARIZE YOUR LEGAL PROBLEM IN YOUR OWN WORDS: