Questionnaire

 

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Client Intake (Tax) 2014

Bankruptcy Intake Sheet – 2014


 

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Section 1: Personal Information

Social Security Number Date of Birth Drivers License Number and State
Taxpayer
Spouse
Section 2: Employment Information














Section 3: Other Financial Information

If Yes, Answer the following:

PlaintiffDefendant


If Yes, Answer the following:


If Yes, Answer the following:


If Yes, Answer the following:


If Yes, Answer the following:

Section 4: Personal Asset information for All Individuals

Personal Bank Accounts: Include ALL checking, Money Market Accounts, Savings Accounts, etc.

12C Add 12a, 12b, and amounts from any attachments

Investments (Stocks, Retirement Accounts, Corporations, Partnerships, etc.)

Type of investment or financial interest: Full Name and Address of financial institution: Current Value: Amount owed as of Account Balance:
13A
13B
13C
13D Total Equity (Add Lines 13a-13c and amounts from any attachments)

Available Credit:

Name and Address of Credit institution and Account Number: Credit Limit: Amount Owed: Available Credit:
14B
14C
14D Total Available Credit (Add Lines 14b-14C and amounts from any attachments):

Personal, rental, and lease property (include all Real Property and land contracts)
Personal Vehicles
Personal Assets (Furniture, Personal Effects, Artwork, Etc.)
Monthly Income and Expense Statement
20 Wages (Taxpayer) 33 Food Clothing and Misc.
21 Wages (Spouse) 34 Housing and Utilities
22 Interest-Dividends 35 Vehicle Ownership costs
23 Net Business income 36 Vehicle Operating costs
24 Net Rental Income 37 Public Transportation
25 Distributions 38 Health Insurance
26 Pension/SS (Taxpayer) 39 Out of pocket healthcare costs
27 Pension/SS (Spouse) 40 Court Ordered Payments
28 Child Support 41 Child Care
29 Alimony 42 Life Insurance
30 Other 43 Taxes (Income and FICA)
31 Other 44 Other Secured Debts (Attach List)
32 Total Income: 45 Total Living Expenses:
***Complete Sections 5 & 6 of the taxpayer is Self-employed***
Section 5: Business Information

Payment Processor(PayPal, google checkout, etc.) Name and Address and Account Number:
Credit Cards accepted by the business:
Credit Card: Merchant Account Number: Merchant Account Provider/Address:
55a.
55b.
55c.
Business Bank Accounts
Account Type: Bank Name and Address: Account Number: Account Balance:
57a.
57b.
Accounts Receivable
AR/Address: Status (age): Due Date: Invoice Number: Amount Due:
58a.
58b.
58c.
58d.
Business Assets (include tools, books, equipment, inventory or other assets used in business)

Include Uniform commercial code (ucc) filings, vehicles, real property owned, leased, or rented by business
Section 6: Sole Proprietorship Information
Monthly Income and Expense Statement
60 Gross Receipts 70 Materials Purchased
61 Gross Rental Income 71 Inventory Purchased
62 Interest 72 Gross Wages & Salaries
63 Dividends 73 Rent
64 Cash 74 Supplies
Other Income (Specify) 75 Utilities/Telephone
65 Other Income (Specify) 76 Vehicle/Gas/Oil
66 Other Income (Specify) 77 Repairs and Maintenance
67 Other Income (Specify) 78 Insurance
68 Other Income (Specify) 79 Current Taxes
80 Other Expenses
69 Total Income: 81 Total Business Expenses
82 Net Business Income:

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