Intake Sheet > Step 1 of 2: Submit

Intake Sheet

In order for us to discuss your case, please fill out the following information as soon as possible so that we may review it immediately:

Is Quik Chek one of your Creditors? *

Have you been receiving any harassing phone calls from creditors? (i.e. before 9am or after 9pm, at work, threats, etc.) *

Phone Number and email address? *

Name *

Current Address (Include County) *

Two Previous Addresses (Address, City, State, Zip Code, Amount of time lived in each place) *

Number of people sleeping at current address? How many of them are listed on your tax return? *

Total Number of Creditors and Total Debt Amount (Approximate) *

Are you being Garnished? *

Have you ever filed for Bankruptcy before? If so, when and what chapter? *

Will you be filing a joint petition of bankruptcy? (i.e. you and your spouse) *

Have you incurred any debt in the last 90 days? If so, how much and to who? *

Have you paid a creditor more than 600.00 in the last 90 days? If so, how much and to who? *

Have any family members loaned you money? If so, how much and to who? *

Have you filed taxes in the last 6 years? Do you have copies of your taxes for the last 3 years? *

If married, did you file jointly in each of the last 3 years? If No, what years did you? *

Do you owe any money in back taxes? If yes, how much and in what years? *

Do you rent, own a home, condominium, vacant lot, or mobile home? *

What is the value of your home? *

What are your monthly payments and what is your pay-off amount on your mortgage? *

Are you behind in your payments? If so, what months? *

Is there a second Mortgage on the real estate? *

What are the monthly payments and what is the pay-off amount on this mortgage? *

Are you behind on these payments? *

How many vehicles do you own? *

Vehicle 1 (Year, make, model, mileage, condition, est. value) *

Do you intend to keep or surrender vehicle 1? *

Have you listed vehicle 1 as collateral for a loan? *

Vehicle 2 (Year, make, model, mileage, condition, est. value) *

Do you intend to keep or surrender vehicle 2? *

Have you listed vehicle 2 as collateral for a loan? *

What was your Gross Income for Last Year? *

What was your Gross Income for the year before last? *

What is the frequency of your current income received? (weekly, bi-weekly, monthly, semi-monthly) *

Gross Average Paycheck Amount *

What is the frequency of your spouses current income? (weekly, bi-weekly, monthly, semi-monthly) *

Spouse's Gross Average Paycheck Amount *

After paying your monthly bills, how much money do you have left over? *

Rent (If you do not own your home) *

First Mortgage payment or mobile home monthly payment *

Second Mortgage (if applicable) *

Third Mortgage (if applicable) *

Lot Payment (if applicable) *

Are real estate taxes included in your mortgage payment? *

What is the amount of taxes not included in your house payment? *

Is your home insurance included in your mortgage payment? *

What is the amount of insurance that is not included in your house payment? *

Amount spent on Electricity and Gas (Monthly) *

Amount spent on water (Monthly) *

Amount spent on telephone (monthly basic service) *

Amount spent on Trash pick-up (Monthly) *

Amount spent on Home Maintenance (Monthly) *

Amount spent on food (Monthly) *

Amount spent on clothing (Monthly) *

Amount spent on Laundry, dry cleaning, soap, etc. (Monthly) *

Amount spent on medical expenses not paid by insurance (Monthly) *

Amount spent on Gasoline-Auto maintenance (Monthly) *

Amount spent on Recreation-Entertainment (Monthly) *

Amount given to Charity (Montly, if claimed on taxes) *

Montly Car Payment amount *

Monthly amount for renters insurance *

Monthly amount spent on Life Insurance (other than employer) *

Monthly amount spent on Health Insurance (other than employer) *

Automobile Insurance (monthly payment) *

Other Monthly Insurance payments (please explain) *

Are any other taxes deducted from your wages? If so, what type? *

Are you paying child support or Alimony? If so, how much? *

Are you making Restitution Payments? If so, how much? *

Are you making payments to someone outside your home? If so, how much? *

Are you paying Union or Professional Dues (not payroll deducted)? If so, how much? *

Child Care, Babysitter-Day Care expenses (monthly) *

School Expenses (monthly) *

College Tuition (not loans) *

Student Loan Repayment *

Personal Items Expenses *

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