Intake Form

Name

Spouse

Address

Spouse Address (if different)

City/St/Zip

Home Phone

Spouse Home Phone (if different)

Cell Phone

Spouse Cell Phone

Email Address

Spouse Email Address

If Internet (Where?)

If Referral (Who?)

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If you were happy with the service provided today please leave me a review on Avvo, Google, Facebook, Twitter, Yelp, or any other social media of your choosing. If you were unhappy for any reason, please let me know and I will do what I can to fix it.

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PLEASE ANSWER THE FOLLOWING QUESTIONS THOROUGHLY:

Have you ever filed Bankruptcy before?

If so, which chapter did you file and what was the date of filing?

How long have you lived in the state of New Mexico for

Have you been served a summons for a current court proceeding?

If so, please explain:

Are you currently being garnished?

If so, by whom?

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PLEASE LIST ALL REAL ESTATE INFORMATION BELOW:

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Collateral Primary Residence

Mortgage Co. Name:

2nd Mtg. Co. Name:

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Loan Type

1st Mtg.

2nd Mtg.

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Mo. Payment

1st Mtg. Payment

2nd Mtg. Payment

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Value

1st Mtg. Value

2nd Mtg. Value

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Payoff

1st Mtg. Payoff

2nd Mtg. Payoff

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Payments Behind

1st Mtg. Payments Behind

2nd Mtg. Payments Behind

Do you own any land or real estate, that you do not live on?

Are there any liens (tax or otherwise) on your home?

If so, please explain:

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PLEASE LIST ALL VEHICLES OWNED, WHETHER THERE IS A LOAN OR NOT:

Vehicle 1 (yr., make & model)

Miles

Value

Total Owed

Mo. Payment

Payments Behind

Lender

Interest Rate

When Purchased (Mo/Yr)

Vehicle 2 (yr., make & model)

Miles

Value

Total Owed

Mo. Payment

Payments Behind

Lender

Interest Rate

When Purchased (Mo/Yr)

Vehicle 3 (yr., make & model)

Miles

Value

Total Owed

Mo. Payment

Payments Behind

Lender

Interest Rate

When Purchased (Mo/Yr)

Vehicle 4 (yr., make & model)

Miles

Value

Total Owed

Mo. Payment

Payments Behind

Lender

Interest Rate

When Purchased (Mo/Yr)

Do you own any of the following assets: Guns, High Value Hobby Equipment or Sporting Goods, Artwork, ATVs, Campers, Trailers, RVs, Airplanes, Boats? If so, please describe:

Are you involved in Worker’s Comp, Civil or Personal Injury lawsuit?

If so, please explain:

Are you current on your tax filings?

If not, what years are not filed?

Are you expecting a tax refund for ANY YEAR?

If so, when?

How much?

If you have ANY TAX DEBT, what years do you owe?

If you own a business, are you current on your CRS return filings?

Do you owe any student loans?

What is the total amount of your unsecured debt (i.e. Credit Cards, Medical Bills, Personal Loans):

How much is an average paycheck from employment or self-employment? How often are you paid?

Your Gross

Your Net

Spouses Gross

Spouses Net

Do you receive any income other than from employment (i.e. social security, disability, retirement)?

If so how much to you earn monthly?

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What are your estimated monthly living expenses, not including bills (such as credit cards, medical, etc.) per month. IF AMOUNTS VARY, PLEASE GIVE ME AN AVERAGE.

Car payment:

Car Insurance:

Rent or Mortgage:

Food:

All Utilities (gas, electric, water, sewer, trash, etc.)

Medical (co-pays, deductibles, prescriptions, etc. on average):

Telephone:

Child Care:

Property Taxes: (don’t list if pd. In mtg. payment)

Child support:

Recreation:

Laundry:

Auto Expense (gas, oil changes, Repairs, tires, etc.

Student Loans

Charitable Contributions: (only those that can be proven)

Home Expenses/maintenance (only if you own):

Other Tax debt (describe):

Health Ins. not deducted from pay:

Clothing:

School Expenses:

Homeowners or Renters Insurance: (don’t list if pd. in mtg. payment)

Life Insurance (cash value?)

Miscellaneous:

Cable, Internet:

Debtor Signature

Date

Spouse Signature

Date