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New Client Form

This short form is totally optional. You can either call us with this information or you can fill this out and forward it to us and we will know quickly if you appear to be a good candidate for bankruptcy relief. If so, we will be happy to schedule your appointment in our Rock Island Office.


This form is for Iowa and Illinois residents only.
1. Personal Info
Last Name:
First Name: Spouse's First Name:
Marital Status: Married Divorced Separated Single Widowed
Address:
City State: Zip:
Phone Number: E-mail:
2. Real Estate (If you do not own real estate, go to section 3)
If you own your home, please enter the following information.
Year Purchased
Current REALISTIC market value estimate $
Total owed on your primary mortgage: $
Total owed on your 2nd mortgage: $
Total owed on your 3rd mortgage: $
Do you still have substantial credit card debt that you had before you bought your home? NoYes
Do you intend to keep or give back your home? KeepGive Back
Is your home in foreclosure? NoYes
Do you own any other real estate, time share, etc.? NoYes
Property Type Property Value Owed On Property Year Purchased
$ $
$ $
$ $
3. Vehicles (If you do not own a vehicle, go to section 4)
Year, Make, & Model Fair Market Value Amount Owed Keep or Give Back
$ $ KeepGive Back
$ $ KeepGive Back
$ $ KeepGive Back
4. Debts
List the estimated amounts for each of the following debt types (do not include debts for home & cars listed above):
Credit Cards $
Medical $
Bank Loans $
Debts to Family Members $
Other Debts $
Have you charged, transferred balances, or taken cash advances exceeding $500 in the past 60 days? NoYes
If yes, how much? $ to whom?
5. Income
Enter your total monthly take home income.
Include employment, unemployment, social security, pension, child support, etc.		 $
6. Business (If you do not own a vehicle, go to section 7)
Is the business incorporated? NoYes
Value of Business Equipment $
Amount OWED on Business Equipme