Bankruptcy Discharge Exception Intake Form
Please complete this form to request a review of a potential bankruptcy discharge exception. All fields are required unless otherwise indicated.
Full Name
*
First Name
Last Name
Email Address
*
example@example.com
Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
Case Number
*
Type of Bankruptcy Filed
*
Please Select
Chapter 7
Chapter 11
Chapter 13
Other
Date Bankruptcy Was Discharged
*
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Type of Discharge Exception Requested
*
Please Select
Student Loan Exception
Tax Debt Exception
Domestic Support Obligation
Fraud or Misrepresentation
Other
Describe the Circumstances and Reason for the Exception
*
Legal Counsel Name (if applicable)
Upload Supporting Documentation (if any)
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