Bankruptcy Questionnaire

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For your convenience, we have provided this online questionnaire to allow our office the opportunity to review your financial situation, and determine if a bankruptcy consultation would be appropriate. A response will be submitted by phone or e-mail within one business day. Our office does not charge for the initial bankruptcy consultation, and we welcome the opportunity to meet with you in person to determine if a bankruptcy filing would provide an adequate solution to your financial difficulties. All information requested is kept secure and confidential, as required by the rules and regulations of the State Bar of Georgia. Submission of inquiries through our website does not create an attorney-client relationship, as the Bankruptcy Code requires a signed representation agreement in order to create an attorney-client relationship.

Intake Form
Name*  
Address  
City, State Zip  
Telephone*   ( ) -
Email*   Please leave this field empty.
Marital Status  

Are you considering bankruptcy for any of the following reasons (select all that apply):

• Pending Foreclosure  Yes No
• Pending Repossession  Yes No
• Lawsuit or Judgment  Yes No
• Wage or Bank Account Garnishment  Yes No
• Past Due Child Support  Yes No
• Unpaid Income Taxes  Yes No
• Medical Bill  Yes No
• Credit Card Debt  Yes No
• Payday or Finance Company Loans  Yes No

What are the sources of household income, including income of spouses? (Select all that apply)
 Wages - salary or hourly Self-Employment Social Security Retirement Other

What is your estimated net monthly household income
from all of the above sources? $

Are you required to file tax returns?  Yes No

If your answer to the above question was “yes”, please answer the following:
• Are you up-to-date in your tax return filings (both state and federal)?  Yes No
• Do you presently owe income taxes for any previous years?  Yes No

Feel free to provide any additional information, or submit any questions, in the following field:

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