Request a Bankruptcy Consultation Download PDF Form Here Bankruptcy Consultation Form Name* First Last Email* Phone*Mailing Address Street Address Address Line 2 City State / Province / Region ZIP / Postal Code AfghanistanÅland IslandsAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarrussalamBulgariaBurkina FasoBurundiCambodiaCameroonCanadaCape VerdeCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongo, Democratic Republic of theCongo, Republic of theCook IslandsCosta RicaCôte d'IvoireCroatiaCubaCuraçaoCyprusCzech RepublicDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatini (Swaziland)EthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacauMacedoniaMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth KoreaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRéunionRomaniaRussiaRwandaSaint BarthélemySaint HelenaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth GeorgiaSouth KoreaSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan Mayen IslandsSwedenSwitzerlandSyriaTaiwanTajikistanTanzaniaThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkeyTurkmenistanTurks and Caicos IslandsTuvaluUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUS Minor Outlying IslandsUzbekistanVanuatuVenezuelaVietnamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabwe Country Are you married?YesNoWhat is your spouse's name? First Last Do you have any children?YesNoHow many children do you have?How old are your children?NameAge How many of your children live with you?Do you pay child support?YesNoDo you owe any back child support?YesNoHow much?Have you ever filed for bankruptcy before?YesNoWhen? Date Format: MM slash DD slash YYYY Was it a personal bankruptcy or a business bankruptcy?PersonalBusinessWhat kind of bankruptcy did you file?Chapter 7Chapter 11Chapter 13Are you subject to any lawsuits or legal actions?YesNoAre there ongoing legal actions related to the collection of debts?YesNoPlease explain:Are you currently employed?YesNoHow much do you make per month?Is your spouse employed?YesNoI don't have a spouse.How much do they make per month?Do you or your spouse receive any additional income such as from social security, an annuity or rental property?YesNoPlease describe:How much is your approximate monthly household income?Is your paycheck being garnished?YesNoHow many credit cards do you currently have?How much do you owe in credit card debt?Do you have medical debt?YesNoHow much medical debt?Is this debt for an ongoing or reoccurring medical problem?YesNoDo you owe any debt from operating a business?YesNoHow much do you owe?Did you personal guarantee the debt?YesNoWhat is the name of your business?What type of business is it?LLCCorporationSole ProprietorshipOtherIf other, please explain:Is the business still in operation?YesNoAre you planning to close down the business?YesNoPlease describe the assets of the business such as equipment, inventory, etc.Please describe the debts of the business:Do you own a home or any other real estate including timeshares?YesNoReal Estate AssetsAddress:Is this your current residence?How much do you currently owe?Describe the property: Have you ever owned a property that has gone through a foreclosure?YesNoPlease describe:Do you own any vehicles including boats or recreational motor vehicles?YesNoListMakeModelMileageLoan Balance When was your most recent purchase of a vehicle? Date Format: MM slash DD slash YYYY Have you ever had a vehicle repossessed?YesNoWhen? Date Format: MM slash DD slash YYYY When did you last file an income tax return? Date Format: MM slash DD slash YYYY Do you owe any back taxes or other IRS debt?YesNoPlease describe:Does your debt include traffic tickets or DUI fines/?YesNoPlease describe:Does your debt include other criminal fines?YesNoPlease describe:Does your debt include student loan debt?YesNoHow much?Are they federal or private student loan debts?FederalPrivateBothPlease select all of the following currently or you expect to apply to you in the future: I have a workers compensation claim I have a personal injury claim I have an inheritance I have a small claims lawsuit I am getting a new job I have sold real estate in the last 2 years I am getting divorced/separated I regularly gamble I have had my identity or credit card information stolen I am subject to paternity/child support/custody lawsuit Please explain:How did you hear about our firm?Referred by (please specify below)Google SearchAvvoFacebookYelpTwitterPlease specify referralPlease Read Carefully* I understand and agree. 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