CLIENT INTERVIEW SHEET
To assist the attorney in answering your questions and concerns, please supply the following information. As with all communications between you and the attorney the information you supply is ABSOLUTELY CONFIDENTIAL.
TODAY’S DATE:__________________
Please check where you FIRST
heard about the law firm of Williams, Malvik & Assoc., P.C.?
T.V._____, Yellow Pages _____, Dex Spine Ad ____, Previous Client _____, Attorney Referral
______,
If Attorney, his/her name:
___________________, Consumer Credit Counseling, ______, Internet___
PROVIDE THE FOLLOWING GENERAL INFORMATION
ABOUT:
A. Husband
or Individual: B. Spouse (if married):
Name: ________________________ Name: ________________________
First Middle Name Last First Middle Name Last
Social Security #: _____-____-_____ Social Security #:
_____-____-_____
Date of Birth: ___________________ Date of Birth:
__________________
Mailing Address: _________________ Mailing Address:
_________________
____________________________ ____________________________
____________________________ ____________________________
Residence Address: ________________ Residence Address: ________________
____________________________ ____________________________
____________________________ ____________________________
Telephone: (____)_______________ Telephone: (____)_______________
E-Mail: _______________________ E-Mail:
_______________________
County: ______________________ County: ______________________
Length of time at above residence:
_____ Length of time at above
residence: _____
Previous residences (If less than 3
years Previous residences (If
less than 3 years
at current residence.) at current residence.)
Address
______________________
Address ______________________
Mo/Yr of residency_____________ Mo/Yr of residency_____________
Address ______________________ Address_______________________
Mo/Yr of residency_____________ Mo/Yr of residency_____________
Address ______________________ Address_______________________
Mo/Yr of residency_____________ Mo/Yr of residency_____________
Tax I.D. number: ________________ Tax I.D. number:
________________
(If in
business) (If
in business)
Other
names used in last six years: Other names used in last six years:
____________________________ _____________________________
____________________________ _____________________________
____________________________ _____________________________
____________________________ _____________________________
Sex: Male Female
Marital Status:
Single Divorced Widowed Married and living together
Married
and living apart
Children living with you:
OR Children you pay support for:
Name
___________________ Age
_____ Name__________________ Age______
Name
___________________ Age
_____ Name _________________ Age______
Name
___________________ Age
_____ Name _________________ Age______
Name
___________________ Age
_____ Name _________________ Age______
Monthly child Support you receive $____________
Monthly child support you must pay $____________
CURRENT
EMPLOYMENT
Employer's name:
__________________ Employer's
name: __________________
___________________________________ ___________________________________
Employer's Address:
________________ Employer's
Address: ________________
___________________________________ ___________________________________
Telephone:
(____)__________________ Telephone:
(____)__________________
Position with employer: _____________ Position with employer:
_____________
Length of time employed: ___________ Length
of time employed: ___________
Self-employment or in business? Self-employment or in business?
___ Yes ___ No ___ Yes ___ No
If more than one employer provide the If more than one
employer provide the
information about other employer. information about other employer.
___________________________________ ___________________________________
___________________________________ ___________________________________
___________________________________ ___________________________________
GROSS INCOME RECEIVED FROM
EMPLOYMENT, TRADE, PROFESSION:
You/Joint-1: Spouse/Joint-2:
1.
2006 (Year to Date): 1. 2006 (Year to Date):
a. Source:_______________________ a. Source:_______________________
b. Amount:
$___________________ b. Amount:
$___________________
2.
Last year 2005: 2.
Last year 2005:
a. Source:_______________________ a. Source:_______________________
b. Amount: $___________________ b. Amount:
$___________________
3.
Previous year 2004: 3.
Previous year 2004:
a. Source:_______________________ a. Source:_______________________
b. Amount:
$___________________ b. Amount:
$___________________
INCOME RECEIVED FROM ALL
OTHER SOURCES:
(Child support, Unemployment
Compensation, Disability, etc.)
You/Joint-1: Spouse/Joint-2:
1.
2006 (Year to Date): 1. 2006 (Year to Date):
a. Source:_______________________ a. Source:_______________________
b. Amount:
$___________________ b. Amount:
$___________________
2.
Last year 2005: 2.
Last year 2005:
a. Source:_______________________ a. Source:_______________________
b. Amount:
$___________________ b. Amount:
$___________________
3.
Previous year 2004: 3.
Previous year 2004:
a. Source:_______________________ a. Source:_______________________
b. Amount:
$___________________ b. Amount:
$__________________
Has there been a change in your income in the past 12
months, or will there be in the next 12?
Y/N
If So,
Please Explain:_____________________________________________________________________
_______________________________________________________________________________________
_______________________________________________________________________________________
GENERAL FINANCIAL INFORMATION
1. How much do
you normally receive for a tax refund between state and federal? $ ______________
2. Have you
received your tax refunds yet, this year?
Yes No (One of Them) (Please circle one)
3. Do you have
a checking or savings account? If yes,
fill in information below.
a. Name of
institution_____________________________________________________
Type
of account____________________
Average $ _______________________
b. Name of institution_____________________________________________________
Type
of account____________________
Average $ _______________________
c. Name of
institution_____________________________________________________
Type
of account____________________
Average $ _______________________
4. Do you owe
money for home, car, signature loans, credit cards or ready reserve account to
any of the Banks or Credit Unions where you have a checking or savings
accounts? _____________ If you do
owe money to your bank, please be advised that your Bank may freeze your bank
accounts: please tell your Attorney even if he does not specifically ask you
about these accounts!
5. Do you have a safe deposit box? If so, where? _________________________________
6. Have you
filed a case under Chapter 13 in the past eight years?____________________
If yes, DATE AND STATE, AND CASE #’
7. Have you
filed a case under Bankruptcy in the past eight years?___________________
If yes, DATE AND STATE AND CASE #’s
8. Do you now have
or have your ever had a V.A., F.H.A. or other Government
Guaranteed
Mortgage Loan?_________________________________________________
9. Please
provide the name, and last known address of any person to whom you pay child
support, or to whom you owe back child support, at this time:
__________________________________________________________
10. Do you owe
child support to a state agency? If so,
please provide their name and address:
________________________________________________________________________________________
11. Are you
being evicted, at this time? Y/N
1. Are you
now, or have you ever been represented by this firm? Yes
No
2.
In the Past 12
Months, have you repaid any money to any relatives or business partners?
Yes
No
3.
In the past 12
months, have you given any gifts of unusual sizes ($200.00 to a family member
or $100.00 to a
Charity), cumulatively?
Yes No
4. If you own a home, has anyone ever sued
you?
Yes No
5. Are you being foreclosed upon or have you had
a repossession?
Yes No
6. Has a pending lawsuit been filed against
you?
Yes No
7. Do you owe any of the following debts?
Student
Loans
Yes No
Taxes
Yes No
Child
Support
Yes No
Alimony Yes No
Criminal
fines
Yes No
Personal injury Yes No
Intentional
injury Yes No
Debts
for fraud Yes No
8. Have you
filed all State and Federal Tax Returns for the previous four years? Yes No
9. Do you
understand that you are required to list all of your debts and all of your
assets and give true and complete answers to all questions asked by the
attorney or his staff? The attorney and
his staff cannot give you permission to do otherwise. If they do, then you should retain another
law firm. Yes No
10. Do you
understand that the penalty for making a false statement in your bankruptcy
petition and schedules is a fine of up to $500,000.00, or imprisonment for up
to 5 years, or both? Yes No
Please Sign
______________________
____________________
Debtor Debtor