Client Intake Form

Name *

Prefix First Name Middle Name Last Name

Social Security Number

Address *

Street Address
Street Address Line 2
City	State / Province
Postal / Zip Code	Country

Mailing Address

Street Address
Street Address Line 2
City	State / Province
Postal / Zip Code	Country

House Phone *

- Area Code Phone Number

Cell Phone

- Area Code Phone Number

E-mail *

Marital Status *

If Divorced or Separated, When?

If Married, Please fill out Spouse's Name

First Name Last Name

Do You Have A Child Support Order In Effect? *

Do You Have a Foreclosure/Sheriff Sale Date On Your Home?

If Yes, When is Sale Date?

Housing *

Monthly Payment *

Does Your Monthly Payment Include Taxes? *

Does Your Monthly Payment Include Insurance? *

Are Your Monthly Payments Current? *

If No, How Many Months Behind Are You?

Mortgage Company/Landlord Name

Market Value

Balance Owed

Second Mortgage/Home Equity Loan Name

Balanced Owed

Monthly Payment

Do You Have A Second Home?

2nd Property

Monthly Payment

Includes Monthly Taxes?

Includes Insurance?

Payments Current?

If No, How Many Months Behind Are You?

Monthly Payment

Mortgage Company/Landlord Name

Market Value

Balanced Owed

2nd Mortgage/Home Equity Loan Name

Balance Owed

Does Your Name Appear On Any Other Real Estate?

If Yes, How Many?

Names Of Dependents And All People Living in Your Household *

First Name Last Name

Name

First Name Last Name

Name

First Name Last Name

Name

First Name Last Name

Name

First Name Last Name

Name

First Name Last Name

Employer *

Address

Street Address
Street Address Line 2
City	State / Province
Postal / Zip Code	Country

Occupation

How Long?

Spouse's Employment Information

Address

Street Address
Street Address Line 2
City	State / Province
Postal / Zip Code	Country

How Long?

Year/Make/Model

Mileage

Finance Company

Date Lease Or Purchase Began

Balance

Monthly Payment

Date Lease Or Purchase Ends

Full Coverage Insurance

Condition

Year/Make/Model

Mileage

Finance Company

Monthly Payment

Balance

Date Lease Or Purchase Began

Date Lease Or Purchase Ends

Condition

Full Coverage

Year/Make/Model

Mileage

Finance Company

Monthly Payment

Balance

Date Lease Or Purchase Began

Date Lease Or Purchase Ends.

Full Coverage Insurance

Condition

Name of Bank or Credit Union

Checking Account

Yes No

Balance

Savings Account

Yes No

Balance

Name of Bank or Credit Union

Checking Account

Yes No

Balance

Savings Account

Yes No

Balance

Do You Have Any Bounced Checks?

Yes No

If Yes, How Many?

Do You Have Any Loans or Credit Cards Through Your Financial Institution?

Yes No

Type Of Account

Where?

Monthly Payment

Balance

Type of Account

Where?

Monthly Payment

Balance

Circumstances Affecting Financial Situation: Job Loss, Garnishment, Medical Bills, Cut in Hours or Pay, Retirement, Credit Card Over Usage, Divorce, Illness, Substance Abuse, Gambling, Other. Please Specify. *

Have You or Your Spouse Ever Filed Bankruptcy Before? *

Yes No

Date FIled

Chapter

Case Number and Judge

Where Filed

Date of Discharge/Dismissal

Date Filed

Chapter

Case Number and Judge

Where Filed

Date of Discharge/Dismissal

Rent/Mortgage Payment

Gas/Electric Bill

Church/Tithe/Charity

Home/Renter's Insurance

Water Bill

Food

Life Insurance

Health Insurance

Auto Insurance

Medical/Dental/Vision (Out of Pocket)

Transportation

Student Loans

Child Support

Taxes

Pet Expenses

Other Utilities (Cable, Dish, Cell)

Cigarettes

Other

Have You Lived in Michigan for the Last 3 Full Years? *

Yes No

If Not, Please Explain

In the Last 6 Months, Have You Received Any Income From Any Source Other Than What You Are Presently Receiving? (I.E. Lump Sum, Retirement Withdraw, Other Jobs, Gifts, Benefits You No Longer Receive)? *

Yes No

Have You Taken Any Cash Advances or Loans in Excess of $500 within the Last 3 Months? *

Yes No

Do You Have Any Stocks, Bonds, Or Mutual Funds? *

Yes No

Have You Paid Any Family Members Money You May Have Owed them in the Last year? * *

Yes No

Are You Suing Anyone Currently or Do You Have a Reason to Believe You Could Sue Someone Currently? *

Yes No

Have You Withdrawn or Taken Any Loans From Your Retirement in Excess of $1,000 within the Last 2 years? *

Yes No

Have You Transferred Any Money or Property to Another Within the Last Two Years? *

Yes No

Have You Paid Any Creditors $600 Within the Last 90 Days? *

Yes No

Name of Creditor

Month/Year Last Used

Balance Owing

Account Holder

Name of Creditor

Month/Year Last Used

Balance Owing

Account Holder

Name of Creditor

Month/Year Last Used

Balance Owing

Account Holder

Name of Creditor

Account Holder

Balance Owing

Account Holder

How Did You Hear About Us? *

Client Intake Form

Client Intake Form

Housing Situation

Additional Property Information

Household Information

Emploment Information

Spouse's Employment Information

Vehicles

Second Vehicle

Third Vehicle

Banking Information

Additional Banking Information

Prior Bankruptcy Filed By You

Prior Bankruptcy Filed by Spouse

Give Us An Idea of Your Monthly Living Expenses