law
Office
Board
Certified -- 106 S. Armenia Ave.
Consumer Bankruptcy Law -- Tampa, FL 33609-3308 Dade City/San Antonio (352) 521-0190
American Board of Certification Appointments also available at: Elsewhere (800) 393-3100
Dade City: 38100 Meridian Ave.,
www.tampabankruptcy.com
New Client Information Sheet
Date:
Name: Social Security # Present
Address: City:
Telephone:
Home Work Zip
Employers
Name and Hourly/monthly/annual salary:
Name of Spouse: Social Sec. # Present
Spouse's
Employer: Telephone:
Spouse
pay Client Email address
PLEASE FILL
OUT COMPLETELY, estimate amounts if you are not sure
Real Estate
owned: Address:
Date
purchased_________
Amount of Down Payment ___________________
Source of
Down payment ___________________________________________
Mtg. Co. payoff mo pmt
value months now due
1st
mtg
2nd
mtg
Any
lump sum payments in last 10 years?
__________________________
Do you own
any other real estate?
Automobiles, boats, 4 wheelers, etc.,
whether you owe on them or not Make, model monthly
months
& year Loan Co payoff
pymt
value now due
1st
veh
2nd
veh
Have you given any creditors a list of your
furniture when you
borrowed money from
them? If so, list these creditors:
Have you
financed any furniture, electronics, jewelry or appliances through any
creditors that you still owe money to?
Owe:
All tax returns filed?_________
IRS/Al/ChS/StL? filed. '09 tax return owed/refund $
Taxes owed due for year
List major
unsecured debts: (estimate amounts owed)
Date of last
credit card charge Amount charged in last 6mo$
List of
creditors:
name of creditor amount owed name of creditor amount owed
Owe relatives?
Repaid relatives last 2 years?
Made any
gifts/transfers worth over $500 last 2 years?
Are you suing
anyone, or do you have the right to sue anyone?
If you have
any type of pension, retirement plan, profit sharing plan, stock option plan,
or annuity: put down name and approximate
amount of money in plan here:
Other than
furniture, clothes & jewelry, do you have anything else worth over $250.00
Estimated
garage sale value of household goods/clothg/jewly ____________
Where did you
hear about this office:
-------- Do
not write below this line ----------------------------
(1)
DEADLINES:
(2)
Notes:
(3) Special
Instructions:
9/10 tpa