Bankruptcy Appointment Form

  • First Name*
  • Last Name*
  • Middle Name
  • Maiden Name
  • Social Security Number
  • Date of Birth*
  • Male/Female*
  • Address*
  • Home Phone Number
  • Cell Phone Number
  • Work Phone Number
  • Email Address
  • Spouse Info

  • First Name
  • Last Name
  • Middle Name
  • Maiden Name
  • Social Security Number
  • Home Phone
  • Cell Phone
  • Work Phone
  • Email Address
  • Spouse Address
  • Marital Status
  • Have you filed bankruptcy before?
  • When?
  • Are you purchasing a home?
  • Are you current on those payments?
  • Do you have a pending foreclosure?
  • Do you owe back property taxes?
  • Do you owe IRS Taxes?
  • Are you purchasing a vehicle?
  • Are you current on the payments for the vehicle(s)?
  • Do you have full coverage insurance on the vehicle(s)?
  • Are you being sued by a creditor right now?
  • Have you ever been sued by a creditor?
  • Have you used your credit cards in the last 60 days?
  • Have you taken out any new credit in the last 180 days?
  • Do you owe any child support or spousal support?
  • Are you current on these payments?
  • Do you have any claims against someone or any company?
  • Income

  • How much do you owe?

  • Credit Cards
  • Medical Bills
  • Loans
  • Payday Loans
  • Rent
  • Car(s)
  • Student Loans
  • Tax Debt
  • Other
  • Expenses

  • Monthly Expenses (Best Estimate)
  • Mortgage - Include Property Taxes and Insurance
  • Utilities- Include Water, Electric, Cable, Sewer, Internet, Cell phone)
  • Food - Include lunches, eating out, snacks)
  • Insurance - Insurance for vehicles and medical coverage
  • Fuel; Trans. - Include Fuel, Repairs, Maintenance. Toll Tags
  • Medical - Include out of pocket monthly expenses only
  • Car Payments - Include all vehicles
  • Debt Payments - Include credit cards, student loans, payday loans, other loans
  • These were created by Congress to make certain you know you are meeting with a Bankruptcy Attorney. They bind you to nothing and are meaningless. By signing these documents, you ARE NOT FILING BANKRUPTCY. You are simply allowing our attorney to discuss your financial situation with you.

    This Agreement is entered into on this day between me/us (hereinafter referred to as the “Client” whether one or more) and The Law firm of Bailey & Galyen (hereinafter the “Attorney” whether one or more). Client has requested the opportunity to consult with and obtain information and advice from the Attorney obtaining relief from debts, including relief from debts by filing bankruptcy under the United States Bankruptcy Code. This agreement is for the purposes of that consultation only. If the Client retains the Attorney to file a bankruptcy, the parties shall execute a separate contract setting forth the fees and other terms of such representations. With respect to the consultation, the parties agree as follows:
    • The fee for the consultation is $ no cost and no obligation.
    • The Attorney shall provide the Client the following:
      1. Analyze the client’s financial circumstances based on information provided by the Client.
      2. To the extent possible, based on the information provided by the Client, advise the Client of the Client’s bankruptcy and non-bankruptcy options.
      3. Advise the Client of the requirements placed upon the Client to file a Chapter 7 or 13 bankruptcy and to provide the client with the information needed if this is not possible.
      4. To the extent possible, quote the Client an estimated fee for the Attorney’s services to provide bankruptcy assistance and/or legal services to the Client.

    If you decide to seek bankruptcy relief, you can represent yourself, you can hire an attorney to represent you, or you can get help ion some localities from a bankruptcy petition preparer who is not an attorney. THE LAW REQUIRES AN ATTORNEY OR BANKRUPTCY PETITION PREPARER TO GIVE YOU A WRITTEN CONTRACT SPECIFYING WHAT THE ATTORNEY OR BANKRUPTCY PETITION PREPARER WILL DO FOR YOU AND HOW MUCH IT WILL COST. Ask to see the contract before you hire anyone. The following information helps you understand what must be done in a routine bankruptcy case to help you evaluate how much service you need. Although bankruptcy can be complex, many cases are routine. Before filing a bankruptcy case, either you or your attorney should analyze your eligibility for different forms of debt relief available under the Bankruptcy Code and which form of relief is most likely to be beneficial for you. Be sure you understand the relief you can obtain and its limitations. To file a bankruptcy case, documents called a Petition, Schedules and Statement of Financial Affairs, as well as in some cases a Statement of Intention need to be prepared correctly and filed with the bankruptcy court. You will have to pay a filing fee to the bankruptcy court. Once your case starts, you will have to attend the required first meeting of creditors where you may be questioned by a court official called a ‘trustee’ and by creditors. If you choose to file a Chapter 7 case, you may be asked by a creditor to reaffirm a debt. You may want help deciding whether to do so. A creditor is not permitted to coerce you into reaffirming your debts. If you choose to file a Chapter 13 case in which you repay your creditors what you can afford over 3 to 5 years, you may also want help with preparing your Chapter 13 plan and with the confirmation hearing on your plan which will be before a bankruptcy judge. If you select another type of relieve under the Bankruptcy Code other than Chapter 7 or Chapter 13, you will want to find out what should be done from someone familiar with that type of relief. Your bankruptcy case may also involve litigation. You are generally permitted to represent yourself in litigation in bankruptcy court, but only attorneys, not bankruptcy petition preparers can give you legal advice.
  • Notice to Clients Who Contemplate Filing Bankruptcy

    The purposes of this Notice and The Statement Mandated by Section 527(b) of the Bankruptcy Cede, which you have been provided as a separate document are to make you aware of some of your obligation should you file bankruptcy.

    You are notified as follows:

    1. All information that you are required to provide with your bankruptcy petition and thereafter in your case is required to be complete, accurate and truthful.
    2. All your assets and all your liabilities are required to be completely and accurately disclosed in the documents filed to commence your case.
    3. The value of each asset which is secured by a lien on such asset must be stated as the replacement value of such asset after reasonable inquiry to establish such value. The replacement value means the replacement value of the date of the filing of the bankruptcy petition without deduction for costs of sale or marketing. With respect to property acquired for personal, family, or household purposes, replacement value mans the price a retail merchant would charge for property of that kind considering the age and condition of the property at the time value as determined.
    4. After reasonable inquiry you are required to state your current monthly income. Current monthly income is defined as “. . .The average monthly income from all sources that the debtor receives (or in a joint case the debtor and the debtor’s spouse receive) without regard to whether such income is taxable income, derived during the 6 month period ending on the last day of the calendar month immediately preceding the date of the commencement of the case if the debtor files the schedule of current income required by section 521(a)(1)(B)(II); OR the date on which current income is determined by the court for purposes of this title if the debtor does not file the schedule of current income required by section 521(a)(1)(B)(II) and includes any amount paid by any entity other than the debtor (or in a joint case the debtor and the debtor’s spouse), on a regular basis for the household expenses of the debtor or the debtor’s dependents (and in a joint case the debtor’s spouse if not otherwise a dependent), but excludes benefits received under the Social Security Act, payments to victims of war crimes or crimes against humanity on account of their status as victims of such crimes, and payments to victims of international terrorism (as defined in section 2331 of title 18) on account of their status as victims of such terrorism.”
    5. After reasonable inquiry you are required to state the amounts set out in section 707(b) (2) of the Bankruptcy Code. Those amounts are defined as in the attachment at the end of this section.
    6. In a case under Chapter 13, after reasonable inquiry, you are required to state your disposable income explained on the attachment at the end of this section.
    7. Information that you provide during your case may be audited pursuant to the provisions of the Bankruptcy Code. Your failure to provide information may result in dismissal of your case or other sanctions, including criminal sanctions.

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