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Initial Interview Questionaire

Bankruptcy Office Intake - Email Form

Bankruptcy Office Intake - Email Form

* - denotes required fields		29 July, 2010
First Name *	Full Middle Name *	Last Name *

Date of Birth
mm/dd/yyyy

Your Email *

	Phone	Best #	What Contact Method Do You Prefer?
Home	- -
Work	- -		Best Time to Call You:
Cell	- -		Best Appointment Time for You:
Alt.	- -

Is Your Spouse Filing? Yes No

	Street Address		Mailing Address (If Different)



	Reasons for filing now:

Do you have car payments? Yes No

Do you owe taxes? Yes No

	Student Loans? Approx. Amt: $
	Payday Loans? Approx. Amt: $
	Credit Cards? Approx. Amt: $
	Medical Bills? Approx. Amt: $
	Child Support? Approx. Amt: $
	Other? Approx. Amt: $

	Do You Have Over 30 Creditors? Yes No
	Do You Have Any:
	Law Suits Against You?	Yes No
	Garnishments?	Yes No
	Foreclosure?	Yes No
	Any Additional Info:

* Enter Security Code

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527(b) Disclosure		U.S.C. 11 527(B)Disclosure

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Kokomo bankruptcy attorneys
Indianapolis bankruptcy attorneys
Indiana bankruptcy lawyers
Learn about the new bankruptcy law changes
Please contact us for a DISCREET and FREE consultation.

Call us at 1-800-966-8447 today!