Client Intake

Online bankruptcy intake forms. Complete the Bankruptcy Questionnaire and Creditor Information first. Use the Business Questionnaire tab only if instructed by the attorney or office.

Required for Every Client

Bankruptcy Questionnaire
Creditor Information

Complete all questions. If a question does not apply, enter “N/A.”

Client Checklist

Federal & State tax returns for the last three years
Paystubs for the last six months
Current Social Security, retirement, benefits, or pension award letter
Color copy of driver license
Color copy of Social Security card
Last three months of bank statements for all active accounts

Bankruptcy Questionnaire Creditor Information Business Questionnaire

Bankruptcy Questionnaire

Complete all questions. If a question does not apply, enter “N/A.” Please list all property, all creditors, and all requested information so it can be properly reviewed.

Name & Residence InformationSection 1

Full Legal Name

Other Names Used

Social Security Number

Date of Birth

Spouse Full Name

Spouse Social Security Number

Residence Address

City / State

Zip

County

Mailing Address

Mailing City / State

Mailing Zip

Phone Number

Phone Type: Home Cell Work

Email Address

Prior BankruptcySection 1a

Have you ever filed or been involved in a prior bankruptcy? Yes No

Have you had a previous bankruptcy discharge within the last 8 years? Yes No

Case #

District or State

Property InformationSection 2

Property Address

HOA? Yes No

Name of HOA

Approximate Purchase Date

Purchase Amount

Name of Mortgage Company

Loan / Account #

Payoff Amount

Date Last Payment Made

Amount of Last Payment

Judgments? Yes No

Is this property in foreclosure? Yes No

2nd Mortgage? Yes No

3rd Mortgage? Yes No

Foreclosing Attorney, if known

2nd Mortgage

2nd Mortgage Company

2nd Loan / Account #

2nd Payoff Amount

2nd Date Last Payment Made

2nd Amount of Last Payment

3rd Mortgage

3rd Mortgage Company

3rd Loan / Account #

3rd Payoff Amount

3rd Date Last Payment Made

3rd Amount of Last Payment

Was this property inherited? Yes No

If inherited, list approximate date and name of person(s) property was inherited from

Does anyone else have interest in this property? Yes No

If yes, list names of person(s) with interest

Do you have any rental property? Yes No

Rental Property Address

Approximate Purchase Date

Purchase Amount

Name of Mortgage Company

Loan / Account #

Payoff Amount

Judgments, foreclosure, 2nd/3rd mortgage, inherited property, other interest, and other rental property details

Mobile Home & Land InformationSection 3

Property Address

Make & Model

Approximate Purchase Date

Purchase Amount

Is the land and mobile home on one mortgage? Yes No

Mobile Home Section 3a

Name of Mortgage Company

Loan / Account #

Payoff Amount

Date Last Payment Made

Amount of Last Payment

Mobile home judgments, foreclosure, 2nd/3rd mortgage, inherited property, other interests, and foreclosing attorney details

Land Section 3b

Name of Mortgage Company

Loan / Account #

Payoff Amount

Date Last Payment Made

Last Payment Amount

Land judgments, foreclosure, 2nd/3rd mortgage, inherited property, other interests, and foreclosing attorney details

Other PropertySection 4

Timeshare Section 4a

Timeshare Property Address

Company

Company Mailing Address

Approximate Purchase Date

Purchase Amount

Estimated Balance Owed

Estimated Value

Burial Plot Section 4b

Do you own a burial plot? Yes No

Burial Site

Location Address

Approximate Purchase Date

Purchase Amount

Estimated Balance Owed

Estimated Value

Lease Section 4c

Do you have a residential lease? Yes No

Name of Landlord / Leasing Company

Mailing Address

Deposit Amount

Monthly Amount

Current? Yes No

Past Due Amount

Last Payment Date

Active Bank AccountsSection 5a

Financial Institution

Account Type: Checking Savings

Account #

Approximate Balance

Other Financial InformationSection 5b

Within the last year, have you closed any bank accounts? Yes No

Financial Institution

Approx. Closed Date

Type: Checking Savings

Account #

Closing Balance Amount

Within the last 2 years, have you had a safety deposit box? Yes No

Financial Institution

Date Opened

Description of Contents

Did you place a security deposit on anything such as utilities? Yes No

Name

Date

Amount

Stocks, Collectibles, Firearms & FurnishingsSection 5

Do you own any stocks, bonds, mutual funds or CDs? Yes No

Stock / Bond / Mutual Fund / CD Name

Amount of Shares

Value Per Share

Do you own any books, prints/pictures, stamps, coins, or sports equipment of substantial value? Yes No

If yes, list details and estimated value

Do you own any firearms? Yes No

Make / Model

Estimated Value

Household Furnishings Section 5c

Please list uncommon household furnishings such as patio furniture, grill, freezer, and any other substantial items.

Item

Estimated Value Amount

Insurance, Jewelry & RetirementSections 5d-5e

Insurance Section 5d

Insurance Company

Type: Term Life Whole Life

Value Amount

Whole Life Cash Value Amount

Policy Owner

Policy #

Jewelry & Other Personal Effects Section 5e

Please list jewelry or personal effects with substantial value, such as watches, gold, pearls, or similar items.

Item

Estimated Value Amount

Retirement - pension, IRA, 401k, etc.

Investment Company

Mailing Address / City / State / Zip

Type: 401k IRA Retirement Pension

Invested Amount

Current funds borrowed? Yes No

Borrowed Amount

Loan Date

Maturity Date

Monthly Payment Amount

Detailed description of how borrowed funds were used

Motor VehiclesSection 5e

Includes vehicles, boats, motorcycles, ATVs, trailers, and similar property.

Make

Model

Year

VIN #

Mileage

Purchase Date (MM/YYYY)

Financed Amount

Finance Company

Mailing Address / City / State / Zip

Current Interest Rate

Monthly Payment Amount

Payoff Amount

Primary Borrower

Co-borrower

Leased? Yes No

Insured? Yes No

Type of Coverage: Full Coverage Liability

Name of Insurance Company / Policy

IncomeSection 6

Occupation Section 6a

Employer

Start Date (MM/YYYY)

Address / City / State / Zip

Pay Frequency: Weekly Bi-weekly Monthly Bi-monthly

Position

Employment Type: W-2 1099

Spousal Income Section 6b

Spouse Employer

Spouse Start Date (MM/YYYY)

Spouse Employer Address / City / State / Zip

Spouse Pay Frequency: Weekly Bi-weekly Monthly Bi-monthly

Spouse Position

Spouse Employment Type: W-2 1099

Other Income Section 6c

Income Type: Social Security - Retirement Social Security - Disability VA - Retirement Pension Food Stamps Child Support

Date Started

Amount

Child Support Details

Court Ordered? Yes No

Do you receive or pay? Receive Pay

Ordered Amount

Current? Yes No

Amount Owed

Date of Last Payment

Last Amount Received

Name of Sender / Receiver

Address / City / State / Zip

Gifts Section 6d

Have you received an inheritance, substantial gift, 401k, pension, or other income within the last year? Yes No

Source

Amount

Funds Were Used To

Household Expenses & DependentsSection 7

Electricity / Gas

Water / Sewer

Cable / Satellite

Internet

Clothes

Home Maintenance

Medication

Health Care / Dental

Auto Maintenance

Gas / Diesel Auto

Auto Insurance

Auto Taxes

Home Taxes

Private Mortgage Insurance

Daycare

Recreation

Club / Union Dues

Other Specify

Other Amount

Other Specify

Other Amount

Dependents Section 7b

How many dependents are in the household?

Relation

Age

Required Forms Complete

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Business Questionnaire

Attorney Requested Only: Complete this tab only if RK Pruitt Law Firm specifically instructed you to complete business forms. This section includes the Business Questionnaire and Profit & Loss Statement.

Business Questionnaire: Basic InformationPage 1

Business Name

County

Business Address

City / State

Zip

Mailing Address, if different

Mailing City / State

Mailing Zip

Phone

Phone Type: Home Cell Work

Are you presently self-employed? Yes No

Date Business Formed

Business Category

Is this business incorporated? Yes NoType:

Do you have any employees? Yes No

Does your business have any W-2 employees? Yes No

W-2 Employees

Name

Relation, if any

Are you current in payroll taxes? Yes No

Payroll Tax Amount Owed

Business Assets, Inventory & TaxesPage 2

Do you have accounts receivable? Yes No

Accounts Receivable Details

Do you have any inventory? Yes No

Inventory

Year

Make / Model

Estimated Value

Purchase Date

Amount of Purchase

Payoff Amount

Does your business owe any federal or state taxes? Yes No

Type: Federal State

Year

Amount Owed

Books, Tax Preparer, License, Insurance & Future DebtPage 2

Who has possession of the books and records? Name

Books and Records Address

Tax Preparer Name

Tax Preparer Address

Do you have a current business license? Yes No

Do you have business liability insurance? Yes No

After your case is filed, do you believe you will incur any additional credit or debt? Yes No

Additional Explanation

Important Business NoticePage 3

Please be advised that self-employed debtors may not take certain actions without specific court authorization, including but not limited to: use of cash collateral, post-petition employment of professionals, payment of pre-petition wages or salary except as allowed, payment of other unsecured pre-petition debt, borrowing money, incurring debt, or selling property other than in the ordinary course of business. You are responsible for maintaining adequate business records and required insurance.

Debtor 1 Signature / Acknowledgment

Debtor 2 Signature / Acknowledgment

Profit & Loss StatementsAuto Calculate

The attorney usually needs 3-6 months of Profit & Loss statements. Complete one statement for each month requested. Use the "+ Add Another Month" button to add additional months.

Profit & Loss Statement

Month

Year

Income

1. Gross Receipts or Sales

2. Cost of Goods Sold

2a. Purchases

2b. Cost of Labor (not employee salaries)

2c. Materials & Supplies

3. Gross Profit

4. Other Income

5. Gross Income

Expenses

6. Business Property - Rent / Lease

7. Employee Salaries / Wages

8. Employee Benefits

9. Equipment Lease Payments

10. Secured Debt Payments

11. Supplies (not included in 2c)

12. Utilities

13. Telephone

14. Repairs & Maintenance

15. Misc. Office Expenses

16. Advertising

17. Travel & Entertainment

18. Professional Fees

19. Insurance

19a. Liability

19b. Property

19c. Vehicle

19d. Workers Compensation

19e. Other Insurance

Taxes

20. Payroll

21. Sales

22. Other Taxes

23. Total Expenses

Total Profit / Loss

Additional Profit & Loss Details

Debtor 1

Debtor 2

Business Forms Review

Use Review Responses to view a simplified attorney summary on this page. Use Save to PDF only when you are ready to create a clean question-and-answer copy.

This secure intake page is designed for client preparation. Please contact the office if you are unsure whether a question applies to you.