INTAKE FORM

INTAKE FORM - INITIAL CONSULTATION (Revised)

INITIAL CONSULTATION

Date:

Name:

Spouse:

Current address (street, city, state, and zip code):

If you have NOT lived at your current address for at least 3 years, please provide prior addresses and approximate dates you lived there:

Please provide your phone number (and that of your spouse if married and filing together):

Please provide your email address (and that of your spouse if married and filing together):

Do you check your email at least once per day?

Yes

Parish:

DEPENDENTS

Please list any dependents living with you at least part of the time. You do not need to provide names, just the relationship (e.g., child or parent) and age.

HOUSEHOLD

What is your marital status (e.g., married, single, divorced, widowed, separated)?

If you are divorced, separated, or widowed, please provide the date this occurred.

Do you own or rent where you live?

OWN

RENT

BANKRUPTCY / TAXES / SUPPORT / LOANS

Have you ever filed for bankruptcy before?

Yes

Did you file a Chapter 7 or a Chapter 13 case?

Ch. 7

Ch. 13

Please provide the date(s) of your previous bankruptcy filing(s).

Did you file your previous bankruptcy (if any) in Louisiana?

Yes

Do you owe any taxes to the IRS?

Yes

If you owe federal taxes, please state the amounts and for which tax years they are owed.

Do you owe any taxes to the Louisiana Department of Revenue, or any other state?

Yes

If you owe state taxes, please state the amounts and for which tax years they are owed.

Do you owe child support or alimony to anyone?

Yes

If you owe child support or alimony, please state to whom the amounts are owed and the amounts.

Do you owe student loans?

Yes

If you owe student loans, please state the amounts and whether they are federal or private loans.

Are your wages being garnished?

Yes

Do you have any judgments against you?

Yes

If you have any judgments, please state the amounts and to whom they are owed.

SECURED LOANS ON REAL PROPERTY

List any Mortgages that you have on your family home, rental property, or other real property.

Mortgage 1 (Creditor, Balance, Monthly payment, Value of Property)

Are you current on Mortgage 1 payments?

Yes

If not, how far behind are you on Mortgage 1?

Mortgage 2 (Creditor, Balance, Monthly payment, Value of Property)

Are you current on Mortgage 2 payments?

Yes

If not, how far behind are you on Mortgage 2?

LOANS ON VEHICLES (BOATS, RVs, MOTORCYCLES, ETC.)

Vehicle Loan 1 (Year, Make, Model, Mileage, Creditor, Balance, Monthly payment)

Are you current on Vehicle 1 payments?

Yes

If not, how far behind are you on Vehicle 1?

Vehicle Loan 2 (Year, Make, Model, Mileage, Creditor, Balance, Monthly payment)

Are you current on Vehicle 2 payments?

Yes

If not, how far behind are you on Vehicle 2?

Vehicle Loan 3 (Year, Make, Model, Mileage, Creditor, Balance, Monthly payment)

Are you current on Vehicle 3 payments?

Yes

If not, how far behind are you on Vehicle 3?

Please list any vehicles owned free and clear, including year, make, model, and mileage.

FINANCIAL ACCOUNTS

For any financial accounts including checking, savings, peer payment apps such as Venmo, CDs, or retirement accounts, please list the financial institution, the last 4 digits of the account number, the type of account, and current balance.

Have you had a safe deposit box or storage unit within the past 1 year?

Yes

If so please list the location and contents.

Have you sold or transferred any property of value within the past 2 years?

Yes

If so, please describe the property sold/transferred, the date of transfer, to whom it was transferred, and what you received, if anything, in return.

Have you owned any businesses within the past 4 years?

Yes

If yes, please provide name, type of business, any assets owned by the business, Federal Tax ID number, dates of operation, and percentage of ownership.

Please list any life insurance policies you have, including whether term/life, name of company, and name of beneficiary.

INCOME

Please list all employers you have had within the past six months, and include your job title and how long you have been employed.

What is your approximate gross monthly employment income? ($)

(Spouse)

If you are married, please list all employers your spouse has had within the past six months, and include your spouse's job title and how long they have been employed.

EXPENSES (AVERAGE AMOUNTS)

Please list your average monthly expenses below:

Rent/Mortgage:

Electricity and/or Gas:

WATER/Sewage/Garbage:

Phone + Cable + Internet:

Streaming Services:

Housekeeping:

Home Maintenance:

Food:

Clothing, Laundry:

Dry Cleaning:

Personal Grooming:

Medical/Dental:

Car Insurance:

Other Insurance:

Domestic Support:

Childcare/Education:

Car Payments:

Taxes: (not including amounts deducted from paystubs)

Transportation:

Charitable Contributions:

Other (please list):

Approximately how much unsecured debt do you owe (e.g., credit cards, unsecured loans, payday loans, medical bills)? ($)

INTAKE form