Lawsuit Intake Form Please enable JavaScript in your browser to complete this form.Please enable JavaScript in your browser to complete this form.Communication with a lawyer through this form does not create an attorney-client relationship and any information submitted will not be confidential or privileged. No information disclosed will prohibit the lawyer from representing a different client in the matter. Do not disclose any information that you would not want released to a third-party. If you do not agree to these terms, please close your browser and do not fill out any of the fields. *I agreePlease take about 10-20 minutes and fill out the requested information. Be as complete as you can. If you do not know the exact answer, use your best guess. If you do not fill out the questionnaire, the initial evaluation will not be provided.Name *FirstLastPhone *Email *Address *Address Line 1Address Line 2City— Select state —AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingStateZip CodeAre you married? *I’m not marriedYesDo you have other debt problems? *Too much unsecured debt (credit cards, personal loans, medical debts)Facing foreclosureFacing auto repossessionOwe back taxesLate on rentUnable to pay student loansIncluding yourself, how many people live in your home? *12345 or moreInclude a spouse, children, any other relatives, or a significant other. Do no include roommates.Is there anyone that lives in your home some of the time, but not every day of the week?YesNoThis could be a college-aged child home for a summer, or a child that only lives with you some of the time.Do you or a spouse receive any of the following? Check all that apply. *Social Security RetirementSocial Security DisabilityMilitary or VA DisabilityOther retirement or pensionAlimony or child supportNone of the aboveAre you employed? *YesNoNot currently, but I have worked in the past six-months.None of the aboveHow often are you paid? *WeeklyEvery two weeks (26 times a year)Twice a month (24 times a year)MonthlyNone of the aboveOn average, how much are you paid each pay period before any taxes or deductions? *Is your spouse employed? *YesNoNot currently, but has worked in the past six-months.How often is your spouse paid? *WeeklyEvery two weeks (26 times a year)Twice a month (24 times a year)MonthlyNone of the aboveOn average, how much is your spouse paid each pay period before any taxes or deductions? *Does anyone regularly give you money each month to help pay household expenses? *YesNoThis could be help child support, an amount an adult pays for living expenses, or other regular amounts you receive to help pay for household expenses.On average, how much do you receive each month for help with household expenses? *What do you estimate is the total amount of unsecured debt you have? *Unsecured debt could be credit card debt, medical debt, personal loans, deficiency balance on a vehicle repossession, etc.What do you estimate is the total amount of unsecured debt you and your spouse have? *Unsecured debt could be credit card debt, medical debt, personal loans, deficiency balance on a vehicle repossession, etc.Do you own or have a mortgage on your home? *I own my home with no mortgageI have a mortgage on my homeI do not own my homeType of property: *Conventional home built on a foundationCondominium or town-homeModular homeDouble-wide mobile homeSingle-wide mobile homeDo you own the land? *I own the land tooI pay lot rentI don’t own the land or pay lot rentEstimated Home ValueHow much do you think your home is worth?Estimated Mortgage BalanceAbout how much do you owe on your mortgage?Are you current on your mortgage payments? *YesNoWhat is the total dollar amount of missed mortgage payments? *Are you trying to keep your home from being foreclosed? *YesNoDo you own any vehicles? *YesNoThis could be a vehicle that you own without any loan, or a vehicle without a loan, including buy-here-pay-here loans. Include automobiles, motorcycles, atv’s, and trailers.How many vehicles do you own *1234More than 4Include automobiles, motorcycles, atv’s, and trailers. If your name is not on the title, you do not need to list that vehicle.What is the year, make, model, trim, and approximate mileage of your vehicle *For example: 2010 Ford F-150 XLT 4×4 crew cab, 150,000 milesIs there a loan on the vehicle? *YesNoWhat is the loan balance? *What is the year, make, model, trim, and approximate mileage of your second vehicle? *For example: 2010 Ford F-150 XLT 4×4 crew cab, 150,000 milesIs there a loan on the second vehicle? *YesNoWhat is the loan balance on your second vehicle? *Please list any additional vehicles any loan balancesHow much moeny are you being sued for? *How much money do you have available to settle the lawsuit? *Submit
