Intake Form

Your Information

Your Name*

First Middle Last

Marital Status*

Other names you've used in the last 6 years

Your Date Of Birth*

Your Address*

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Your County of Residence*

Your Home Phone*

Your Cell Phone

Your Email*

Occupation*

Name/ Address of Employer:*

Length of Employment:*

How did you hear about us?*

Postcard
TV Weekly Shopper/Redbook
Yellowpages
Internet
Referral

Your Spouse's Information

Spouse's Name

First Middle Last

Other names your spouse used in the last 6 years

Spouse's Date Of Birth

Spouse's Address

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Spouse's County of Residence

Spouse's Home Phone

Spouse's Cell Phone

Spouse's Occupation

Name/ Address of Employer of Spouse:

Spouse's Length of Employment:

Bankruptcy Questions

Have you filed for bankruptcy within the last 8 years?*

Yes
No

If yes, Fill Out the Fields Below*

Location Where Filed	Case Number	Date Filed

Do you or your spouse or your children have a Personal Injury Claim of any kind?*

Yes
No

Have you or spouse had a lawyer represent you before?*

Yes
No

Divorced?*

Yes
No

Married now?*

Yes
No

Do you have any interest in real estate of land or anyone else's bank account?*

Yes
No

Enter the Types of Debt You Have

Just estimate the amount to the best of your ability

Credit Card Debt

Tax Debt

Accident w/o Insurance

Medical Debt

Student Loans

Lawsuits

NSF Checks

Check Loans

Tickets

Past Due Utilities

Repossessions

Foreclosures (Now or Past)

Child Support

Personal or Bank Loan

Mortgage/Home Equity/Time Share

Current Income

Just estimate the amount to the best of your ability

List all dependants of you and your spouse, their ages, and relationship to you

Name	Age	Relationship

I Get Paid*

Weekly
Bi-Weekly
2x/Month
Monthly

Income (gross Pay)*

Overtime Income*

My Spouse Gets Paid

Weekly
Bi-Weekly
2x/Month
Monthly

Spouse's Income (gross Pay)

Spouse's Overtime Income

Other Income

Alimony	Social Security	Unemployment	Pension	Property / Rental	Income from Operation of Business	Other Income:

Spouse's Other Income

Alimony	Social Security	Unemployment	Pension	Property / Rental	Income from Operation of Business	Other Income:

Do you expect any changes in your income or expenses over the next year? If so, please explain below:

Current Monthly Expenses

Do you and your spouse maintain separate households?*

No
Yes

The following questions ask for your expenses each month. If you are unsure of the amount you pay each month, but know the amount for a different period (per week, per day, every 2 months, etc.) write the amount and the frequency that you pay the amount. Indicate how much you pay for each item each month:

1st Household

1. Your Rent or your home mortgage

Does that amount include real estate taxes

yes
no

Does it include property insurance?

yes
no

2. Electricity and heating

3. Water and Sewage

4. Telephone service / long distance

5. Cable/ Satellite

6. Cell Phone

7. Home maintenance, including repairs and general upkeep

8. Food

9. Clothing

10. Laundry and Dry Cleaning

11 . Medical and Dental Expenses

12. Transportation

13. Entertainment, Recreation, Newspapers, Magazines

14. Charitable Contributions

15. Insurance not deducted from paycheck

a. Homeowner's or Renter's insurance	b. Life insurance	c. Health insurance	d. Auto insurance

Other Insurance not deducted from paycheck

Insurance type	Amount

16. Taxes not deducted from paycheck

17. Installment payments for car, furniture, etc.

Type	Amount

18. Alimony, maintenance, support paid to others

19. Payments for support of dependants not living at home

20. Expenses from operation of business

21. Other expenses not listed above such as pet care or hair care:

2nd Household

1. Rent or home mortgage: