Thank you for selecting our firm.
In order that we may better serve you, please provide
us with the following information:
YOU (Please Print) / YOUR SPOUSE Mr. Mrs. Ms. Miss
LEGAL NAME (Last, First and Middle): / Mr. Mrs. Ms. Miss
LEGAL NAME (Last, First and Middle):
SOCIAL SECURITY NO: / SOCIAL SECURITY NO:
DATE OF BIRTH: / DATE OF BIRTH:
CONTACT INFORMATION:
HOME (______)______
CELL (______)______
WORK (______)______Ext.______
E-MAIL______@______
Check if we can send you additional information by e-mail / CONTACT INFORMATION:
HOME (______)______
CELL (______)______
WORK (______)______Ext.______
E-MAIL______@______
Check if we can send you additional information by e-mail
PHYSICAL ADDRESS (Please include City, State, Zip): / PHYSICAL ADDRESS (Please include City, State, Zip):
MAILING ADDRESS (Include City, State, Zip):
(Only if different from your physical address) / MAILING ADDRESS (Include City, State, Zip):
(Only if different from your physical address)
What county do you live in? / What county do you live in?
HAVE you lived at this address
continuously for the past 3 Years? Yes No
EMPLOYER NAME ADDRESS / EMPLOYER NAME ADDRESS
OCCUPATION /JOB TITLE: / OCCUPATION /JOB TITLE:
LENGTH OF EMPLOYMENT: / LENGTH OF EMPLOYMENT:
Has your vehicle been repossessed in the last 21 days? Yes No
If Yes, what date was it repossessed?
Has Your Home Been Scheduled for a foreclosure sale? Yes No
If Yes, When is the Foreclosure Date and Time?
What are you worried about?
Medical bills Loss of job Foreclosure/Eviction Credit card Debt
Repossession Wage Garnishment Utility shutoff New job with lower income
Lawsuits Aggressive collection agencies Other:______
Why did you select our firm?
Advertising in yellow pages Sign in front of office “Leading Illinois Attorney’s” guidebook
Internet Billboard You are a previous client
Referred by Attorney Referred by friend
Radio Television ads Other:______
Do you know anyone who is a current or former client at our firm? Yes No
If YES, please list that person’s name and relationship to you:
h
Have you ever filed bankruptcy before? / ☐ Yes ☐ NoPermission to Perform Computer Searches and
Acknowledgement of Receipt of Notices
I hereby authorize and give permission to ______(hereinafter “Attorney”) to run a computer searches for my assets and current and past address using records gathered by computerized database services. This search will access several databases, including but not limited to Westlaw, Lexis Comprehensive Reports, DMV records, real estate records, personal property records, and credit reports, in an effort to give the Attorney a more accurate picture of my assets and liabilities. I understand that I am still responsible for disclosing all of my assets and liabilities and that these searches are intended to verify the information I provide.
I also acknowledge that today I received and reviewed from Attorney, a copy of the Notice to Individual Debtor Under §342(b) of the Bankruptcy Code (Form 2010), Notice to Individual Debtor under §527(a)(2) of the Bankruptcy Code, Notice to Individual Debtor under §527(b) – IMPORANT INFORMATION ABOUT BANKRUPTCY ASSISTANCE SERVICES FROM AN ATTORNEY OR BANKRUPTCY PETITION PREPARER and Notice to Individual Debtor under §527(c) – INSTRUCTIONS ON PROVIDING INFORMATION REQUIRED BY BANKRUPTCY LAW. If my spouse was not present when I received a copy of these notices, I hereby acknowledge receipt of these notices for my spouse and promise to provide my spouse with either a copy of these notices or the opportunity to read and review the copies I received within the next 24 hours.
______
Signature Date SignatureDate
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