Intake Form IV | Illini Legal Services

Bold labels and indicate required information.

Details Name Please enter your name.

Street Address Please enter your street address.

City Please enter the name of your city.

State Please choose your state of residence. ZIP Code Please enter a valid ZIP code. You may use 0-9, spaces and the ( ) - + characters.

E-mail Address

Please enter a valid e-mail address.

Home Phone Number Please enter a valid home phone number. You may use 0-9, spaces and the ( ) - + characters.

Business Phone Number Please enter a valid business phone number. You may use 0-9, spaces and the ( ) - + characters.

Mobile Phone Number Please enter a valid mobile phone number. You may use 0-9, spaces and the ( ) - + characters.

Fax Number Please enter a valid fax number. You may use 0-9, spaces and the ( ) - + characters.

Please indicate if you intend to file a joint bankruptcy petition. I intend to file a joint bankruptcy petition.

I will not be filing a joint bankruptcy petition.

If you intend to file a joint bankruptcy petition, please enter your name and your spouses name, including middle initial. Please enter your name and your spouses name.

If you intend to file a joint bankruptcy petition, please list your residence address, including county. Please list your residence address, including county.

If you intend to file a joint bankruptcy petition, how long have you been at this address. Please indicate how long have you been at this address.

If you intend to file a joint bankruptcy petition, please list any other residences and how long you have owned them. Please list any other residences and how long you have owned them.

Please indicate if you have used any other name(s) in the last six years. I have used a different name in the last six years.

I have not used a different name in the last six years.

If you have used any other name(s) in the last six years, please enter those name(s). Please enter any other name(s) you've used.

Please indicate your marital status. I am single.

I am separated.

I am married.

I am divorced.

If you are married, how long have you have been married? Please indicate how long have you have been married.

If you are divorced, how long it has been since your divorce. Please indicate how long it has been since your divorce.

If you live with any minor children, please enter their birth dates. Please enter the birth dates of any minor children living with you.

Child Support Paid How much child support is paid for child number one Please enter the child support paid for child number one.

Please enter child number one's birth date. Please enter child number one's birth date.

How much child support is paid for child number two Please enter the child support paid for child number two.

Please enter child number two's birth date. Please enter child number two's birth date.

How much child support is paid for child number three Please enter the child support paid for child number three.

Please enter child number three's birth date. Please enter child number three's birth date.

How much child support is paid for child number four Please enter the child support paid for child number four.

Please enter child number four's birth date. Please enter child number four's birth date.

Are any child support payments past due? I have past due child support payments.

I have no past due child support payments.

If any child support payments are past due, please enter the past-due balance. Please enter the past-due balance on your child support payments.

Husband's Employment How long has he been employed at his current job? Please indicate how long the husband has been employed at his current job.

What is the husband's occupation? Please enter husband's occupation.

How often is the husband paid? Husband is paid weekly.

Husband is paid every other week.

Husband is paid monthly.

Husband is paid based on a different schedule.

Enter gross amount paid per pay period. Please enter gross amount paid per pay period. The gross amount is the total compensation, without deductions.

Enter net amount paid per pay period. Please enter net amount paid per pay period. The net amount is "take-home pay," the amount of compensation after deductions.

Wife's Employment How long has the wife been employed at her current job? Please indicate how long the wife has been employed at her current job.

What is the wife's occupation. Please enter wife's occupation.

How often is the wife paid? Wife is paid weekly.

Wife is paid every other week.

Wife is paid monthly.

Wife is paid based on a different schedule.

Enter gross amount paid per pay period. Please enter gross amount paid per pay period. The gross amount is the total compensation, without deductions.

Enter net amount paid per pay period. Please enter net amount paid per pay period. The net amount is "take-home pay," the amount of compensation after deductions.

If you are receiving income from other sources (e.g. second job, investments, social security, child support, worker's compensation, rental income, etc.), please enter the source and the amount. Please enter the source and the amount of income received from other sources.

Do you owe any money to the Internal Revenue Service? I owe money to the Internal Revenue Service.

I do not owe money to the Internal Revenue Service.

If you owe money to the Internal Revenue Service, how many years have you owed money to the IRS? How many years have you owed money to the IRS?

If you owe money to the Internal Revenue Service, how much money do you owe to the IRS? How much money do you owe to the IRS?

Do you have any unpaid student loans? I have unpaid student loans.

I do not have any unpaid student loans.

If you have unpaid student loans, please enter the unpaid balance. Please enter the unpaid balance of your student loans.

Monthly Expenses If you are a renter, how much rent do you pay each month? Please enter monthly rent expense.

How much real estate tax do you pay each month? Please enter monthly real estate tax expense.

How much do you pay for electricity each month? Please enter monthly electric expense.

How much do you pay for home maintenance each month? Please enter monthly home maintenance expense.

How much do you pay for natural gas/heating each month? Please enter monthly natural gas/heating expense.

How much do you pay for life insurance each month? Please enter monthly life insurance expense.

How much do you pay for water each month? Please enter monthly water expense.

How much health insurance do you pay each month? Please enter monthly health insurance expense.

How much do you pay for your phone each month? Please enter monthly phone expense.

How much auto insurance do you pay each month? Please enter monthly auto insurance expense.

How much do you pay for cable each month? Please enter monthly cable expense.

How much homeowner/renter insurance do you pay each month? Please enter monthly homeowner/renter insurance expense.

How much do you pay for trash each month? Please enter monthly trash expense.

How much is your house payment each month? Please enter monthly house payment expense.

Do you pay anyone spousal support (alimony)? I pay someone spousal support (alimony).

I do not pay anyone spousal support (alimony).

If you pay anyone spousal support (alimony), please enter the name(s) of the recipient and the amount you pay. Please enter the name(s) of the recipient(s) and the amount you pay to each in spousal support.

Please indicate whether or not you own or are purchasing a home or other real property. I own or am purchasing a home or other real property.

I do not own nor am I purchasing a home or other real property.

Please enter your tax assessed value. Please enter your tax assessed value.

Mortgage Loans Please enter your first mortgage loan balance. Please enter your first mortgage loan balance.

Please indicate if your first mortgage loan is past due. My first mortgage loan is past due.

My first mortgage loan is not past due.

If your first mortgage loan is past due, please enter the past due balance. Please enter the past due balance of your first mortgage loan.

Please enter your second mortgage loan balance. Please enter your second mortgage loan balance.

Please indicate if your second mortgage loan is past due. My second mortgage loan is past due.

My second mortgage loan is not past due.

If your second mortgage loan is past due, please enter the past due balance. Please enter the past due balance of your second mortgage loan.

Please enter your third mortgage loan balance. Please enter your third mortgage loan balance.

Please indicate if your third mortgage loan is past due. My third mortgage loan is past due.

My third mortgage loan is not past due.

If your third mortgage loan is past due, please enter the past due balance. Please enter the past due balance of your third mortgage loan.

Please indicate if you are facing foreclosure. I am facing a foreclosure.

I am not facing a foreclosure.

If you are facing foreclosure, please enter the foreclosure date. Please enter the foreclosure date.

Please enter any liens against your property. Please enter any liens against your property. A lien is a legal claim against a property, such as for unpaid bills for home improvements.

Vehicle Loans Please enter the year, make, and model of vehicle number 1. Please enter the year, make, and model of vehicle number 1.

Please provide the estimated loan balance of vehicle number 1. Please provide the estimated loan balance of vehicle number 1.

Please indicate if your loan for vehicle number 1 is past due. The loan for vehicle number 1 is past due.

The loan for vehicle number 1 is not past due.

If your loan for vehicle number 1 is past due, please enter past due balance. Please enter the past due balance on the loan for vehicle number 1.

Please enter the year, make, and model of vehicle number 2. Please enter the year, make, and model of vehicle number 2.

Please provide the estimated loan balance of vehicle number 2. Please provide the estimated loan balance of vehicle number 2.

Please indicate if your loan for vehicle number 2 is past due. The loan for vehicle number 2 is past due.

The loan for vehicle number 2 is not past due.

If your loan for vehicle number 2 is past due, please enter past due balance. Please enter the past due balance on the loan for vehicle number 2.

Please enter the year, make, and model of vehicle number 3. Please enter the year, make, and model of vehicle number 3.

Please provide the estimated loan balance of vehicle number 3. Please provide the estimated loan balance of vehicle number 3.

Please indicate if your loan for vehicle number 3 is past due. The loan for vehicle number 3 is past due.

The loan for vehicle number 3 is not past due.

If your loan for vehicle number 3 is past due, please enter past due balance. Please enter the past due balance on the loan for vehicle number 3.

Owned Vehicles

These are vehicles that are owned outright and have no loans associated with them.

Please enter the year, make, and model of owned vehicle number 1. Please enter the year, make, and model of owned vehicle number 1.

Please enter the estimated value of owned vehicle number 1. Please enter the estimated value of owned vehicle number 1.

Please enter the year, make, and model of owned vehicle number 2. Please enter the year, make, and model of owned vehicle number 2.

Please enter the estimated value of owned vehicle number 2. Please enter the estimated value of owned vehicle number 2.

Please indicate if you have purchased any secured items in the last two years on which you still owe money. I still owe money on secured items (electronics, boats, jet ski, appliances, etc.) that I purchased in the last two years.

I do not owe money on any secured items (electronics, boats, jet ski, appliances, etc.) purchased in the last two years.

Please indicate if you've taken out a loan from a finance company, credit union, bank or any other place and secured the loan by household items or other type of secured collateral. I have taken out a loan from a finance company, credit union, bank or any other place and secured the loan by household items or other type of secured collateral.

I have not taken out any loans from a finance company, credit union, bank or any other place and secured the loan by household items or other type of secured collateral.

Please enter your creditors names. Please enter your creditors' names.

Please enter the estimated balance owed on your medical bills. Please enter the estimated balance owed on your medical bills.

Please enter the estimated balance owed on overdraft or NSF (not sufficient funds) checks. Please enter the estimated balance owed on NSF checks.

Please enter the total estimated balance owed on all credit cards. Please enter the estimated balance owed on all credit cards.

Please enter the estimated balance owed on miscellaneous bills. Please enter the estimated balance owed on miscellaneous bills.

Please enter approximate date of the last time you used any of your credit cards. Please enter approximate date of the last time you used any of your credit cards.

Please enter how much total owed on cards has increased in the last 12 months. Please enter how much total owed on cards has increased in the last 12 months.

Please indicate if you have had any new cards issued in the last 12 months. A new card has been issues to me in the last 12 months.

No new cards have been issued to me in the last 12 months.

Please indicate if you anticipate a tax refund. I anticipate a tax refund.

I do not anticipate a tax refund.

If you are anticipating a tax refund, please enter the anticipated amount. Please enter the anticipated amount of your tax refund.

Please indicate if you are eligible for the Earned Income Credit. I am eligible for the Earned Income Credit.

I am not eligible for the Earned Income Credit.

If you are eligible for the Earned Income Credit, please enter the amount. Please enter the amount of Earned Income Credit.

Please list all judgments, lawsuits, liens and garnishments against you. Please list all judgments, lawsuits, liens and garnishments against you.

Describe any special concerns. Please describe any special concerns.

How did you hear about this Web site? How did you hear about this Web site? Please choose one.

The use of the Internet or this form for communication with the firm or any individual member of the firm does not establish an attorney-client relationship. Confidential or time-sensitive information should not be sent through this form.

Please verify that you have read the disclaimer. I have read the disclaimer.

Bankruptcy Intake Form