Clark & Washington, P.C.
(770) 488-9334
www.cw13.com
Client Information Worksheet
Client Information:
First Name: ____________________________
Middle Name: __________________________
Last Name: ____________________________
Other Names Used In The Past 8 Years: ________________________
__________________________________________________________
Social Security #: _____________
Date of Birth: _________________
Marital Status: __Married __Single
__Divorced __Widow __Separated
Street Address: _____________________________________________
City:
Mailing Address: ____________________________________________
Have you moved to
Have you filed bankruptcy before? _____
If yes, when? ________ Where? __________________________
Case No(s) __________________________ Type: __ Chapter 7__Chapter 13
Are any of the cases listed above still open? ________________
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: _________________________________________
How Long At This Job?: ____________
Job Title: ________________________
Do you regularly receive paystubs or other evidence of your wages from your employer? Please Select: ___Yes ___No ___N/A
How often do you get paid?
Please Select: ___Weekly ___Bi-Weekly ___Semi-Monthly ___Monthly
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: _____________
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? ___ Yes ___No
Do you own any interest in an education individual retirement account or a qualified state tuition program?: ___Yes ___No
Dependents
Relationships and Ages:
1. Relation: ______________ Age: ___
2. Relation: ______________ Age: ___
3. Relation: ______________ Age: ___
4. Relation: ______________ Age: ___
5. Relation: ______________ Age: ___
6. Relation: ______________ Age: ___
Other than above, does anyone else live with you?: ________
Do you contribute to the support of anyone else?: ___Yes ___No
If so, explain: _________________________________________________________
_____________________________________________________________________
How did you hear
about us?
___Mail advertisement ___Foreclosure Mail advertisement ___Garnishment Mail Advertisement ___Lawsuit Highway Sign ___Referral Daily Report ___Newspaper ___Previous Client ___TV/Radio ___Website ___Yellow Pages
___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:
Mailing Address: _________________________________________________________
Did you move to
Have you ever filed for bankruptcy?: ___Yes ___No
Home Phone: _____________
Cell/Pager: _____________
Work Phone: _____________
Email:____________________ Note: Necessary to receive notifications about your case.
Employer:
Payroll Address: _______________________________________
Length Of Employment: ___________
Job Title: _______________________
Do you regularly receive paystubs or other evidence of your wages from your employer? Please Select: ___Yes ___No ___N/A
How often do you get paid? ___Weekly ___Bi-Weekly ___Semi-Monthly ___Monthly
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!!!
Any missing information may result in additional cost in the future.
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Creditor Name: ________________________________________
Creditor Address 1: ____________________________________
Creditor Address 2: ____________________________________
City:
Creditor Phone: _______________ Creditor Acct #: ____________________
Collateral: ____________________ Balance Owed: _________________
Monthly Payment: ______________ Date Debt Incurred/Purchased: _____________
Collateral Value: _______________ # Months Behind: __________
Creditor Name: ________________________________________
Creditor Address 1: ____________________________________
Creditor Address 2: ____________________________________
City:
Creditor Phone: _______________ Creditor Acct #: ____________________
Collateral: ____________________ Balance Owed: _________________
Monthly Payment: ______________ Date Debt Incurred/Purchased: _____________
Collateral Value: _______________ # Months Behind: __________
Creditor Name: ________________________________________
Creditor Address 1: ____________________________________
Creditor Address 2: ____________________________________
City:
Creditor Phone: _______________ Creditor Acct #: ____________________
Collateral: ____________________ Balance Owed: _________________
Monthly Payment: ______________ Date Debt Incurred/Purchased: _____________
Collateral Value: _______________ # Months Behind: __________
Creditor Name: ________________________________________
Creditor Address 1: ____________________________________
Creditor Address 2: ____________________________________
City:
Creditor Phone: _______________ Creditor Acct #: ____________________
Collateral: ____________________ Balance Owed: _________________
Monthly Payment: ______________ Date Debt Incurred/Purchased: _____________
Collateral Value: _______________ # Months Behind: __________
Creditor Name: ________________________________________
Creditor Address 1: ____________________________________
Creditor Address 2: ____________________________________
City:
Creditor Phone: _______________ Creditor Acct #: ____________________
Collateral: ____________________ Balance Owed: _________________
Monthly Payment: ______________ Date Debt Incurred/Purchased: _____________
Collateral Value: _______________ # Months Behind: __________
Creditor Name: ________________________________________
Creditor Address 1: ____________________________________
Creditor Address 2: ____________________________________
City:
Creditor Phone: _______________ Creditor Acct #: ____________________
Collateral: ____________________ Balance Owed: _________________
Monthly Payment: ______________ Date Debt Incurred/Purchased: _____________
Collateral Value: _______________ # Months Behind: __________
Creditor Name: ________________________________________
Creditor Address 1: ____________________________________
Creditor Address 2: ____________________________________
City:
Creditor Phone: _______________ Creditor Acct #: ____________________
Collateral: ____________________ Balance Owed: _________________
Monthly Payment: ______________ Date Debt Incurred/Purchased: _____________
Collateral Value: _______________ # Months Behind: __________