Atlanta GA Bankruptcy Attorney Chapter 7, Chapter 13, Foreclosure

Client Information Worksheet

We are happy to offer you a FREE CONSULTATION on debt relief.
After completing this form, please PRINT it out and bring it with you to your appointment.
Note: If you are married, please fill out all of the information for both spouses
(even if the spouse is not filing).
Click here if you would prefer to print this page to fill out by hand.

Client Information:

First Name:
Middle Name
Last Name:
Other Names Used In The Past 8 Years:

SSN:	Date of Birth:		Marital Status:
Street Address:
City:	State:	Zip:	County:
Client Mailing Address:
Mailing City:		Mailing State: Mailing Zip:

Have you moved to Georgia in the last 2 years? Yes If so, when?
Have you filed bankruptcy before? Yes
If yes, when?		Where?
Case No(s) Type:

Are any of the cases listed above still open? Yes
Client Phone: Client Cell/Pager: Client Work Phone:
Email: Note: Necessary to receive notifications about your case.

Employment Information:

Client Employer Name:
Client Payroll Address:
Payroll City: Payroll State: Payroll Zip:
How Long At This Job?:	Job Title:
Do you regularly receive paystubs or other evidence of your wages from your employer?
How often do you get paid?
GROSS INCOME (before deductions) per pay period (including over time pay):
Take home (after deductions) per pay period:
Check any deductions from your pay: 401(k) Retirement Plan Child Support Union Dues Uniforms Additional Deductions
Other Income: Source(s) of other income:
What was your total GROSS INCOME from all sources during the past six (6) months?:
What was your SPOUSE's total GROSS INCOME from all sources during the past six (6) months?:
Total income: This Year Last Year Year Before Last
(Self) (Spouse)
What was the last year that you filed a tax return?:
What state did you live in when you filed it?:
The last year you were required to file a return?:
Did you file all tax returns for the past 4 years?:
Do you own any interest in an education individual retirement account or a qualified state tuition program?:

Dependents Relationships and Ages:

1. Relation: Age:	4. Relation: Age:
2. Relation: Age:	5. Relation: Age:
3. Relation: Age:	6. Relation: Age:
Other than above, does anyone else live with you?:
Do you contribute to the support of anyone else?: If so, explain:

How did you hear about us?
Other, please specify:

Spouse Information:
If you are married (even if your spouse is not filing), please complete the spouse's information below:

First Name:
Middle Name:
Last Name:
Please list any other name(s) you are known by:
Social Security #:		Date of Birth:
Street Address:
City: State: Zip:
Mailing Address:
Mailing City: Mailing State: Mailing Zip:
Did you move to Georgia in the last 2 years?:
Have you ever filed for bankruptcy?:
Home Phone:		Cell/Pager:
Work Phone:
Email: Note: Necessary to receive notifications about your case.

Employer:
Payroll Address:
Payroll City: Payroll State: Payroll Zip:
Length Of Employment: Job Title:
Do you regularly receive paystubs or other evidence of your wages from your employer?
How often do you get paid?
GROSS INCOME (before deductions) per pay period (including over time pay):
Take home (after deductions) per pay period:
Payroll deductions other than taxes and social security: 401(k) Retirement Plan Child Support Union Dues Uniforms Additional Deductions

Next you will be asked to list all of your debts. If your list is partially complete, then the information received in your consultation will be partially correct!!!

For an accurate consultation, you will need to provide us with a list of your creditor information. Please check the box that you are ready to proceed and click the "ENTER CREDITORS" button below.

� 2003-2008 Clark & Washington, P.C.
3300 Northeast Expressway Bldg. 3 Atlanta, GA 30341
We are a debt relief agency. We help people file for bankruptcy relief under the Bankruptcy Code.

Disclaimer: This Website contains general information about various areas of bankruptcy.
It is highly recommended that persons with debtor/creditor problems seek the advice of an
attorney. The information on this Website is not intended to be legal advice and viewers
should consult with an attorney.

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