Chapter 7 Bankruptcy Intake Checklist

Chapter 7 Bankruptcy Intake Checklist

Information Needed Your Response
Client Information:
Full Name:
Address:
Phone Number:
Email Address:
Social Security Number:
Date of Birth:
Marital Status:
Household Information:
Names and ages of dependents:
Any dependents living outside the household?
Income Information:
Employment Details (for each job in the past 6 months):
- Employer Name:
- Employer Address:
- Job Title:
- Gross Monthly Income:
- Net Monthly Income:
Spouse’s Employment Details (if applicable):
- Employer Name:
- Employer Address:
- Job Title:
- Gross Monthly Income:
- Net Monthly Income:
Additional Sources of Income:
- Child Support/Alimony:
- Social Security Benefits:
- Unemployment Benefits:
- Pension/Retirement Income:
- Rental Income:
- Other Income (please specify):
Expense Information:
Monthly Household Expenses:
- Rent/Mortgage Payment:
- Utilities (electricity, water, gas, etc.):
- Groceries:
- Transportation (car payments, fuel, public transit):
- Childcare/Education:
- Medical Expenses (insurance premiums, out-of-pocket
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