Your Information:Name* First Middle Last Do you have a spouse* Yes No Date of Birth*Home Address* Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Best Phone Number To Reach You*Email* County of Residence*Have You Lived in Michigan For The Past 6 Months?* Yes No Members of your householdList all members of your household, their age, and what relation they are to you (this includes anyone who lives with you and shares income and expenses, even if not related):NameAgeRelation to you Employer*Occupation/Job Title*Length of employment*What is your Annual Salary or Hourly Wage*How often are you paid*WeeklyBi-weeklyMonthlyOtherDo you receive salary bonuses*Do you collect Social Security* Yes No Do you receive Alimony/Child Support* Yes No Do you receive Unemployment Compensation* Yes No How Much Do You Receive in Social Security Monthy?*How Much Do You Receive in Alimony/Child Support Monthy?*How Much Do You Receive in Unemployment Compensation Monthy?*List all income you received from ANY source not listed aboveDo you owe any of the following:Income Taxes* Yes No Student Loans* Yes No Alimony/Child Support* Yes No Criminal Fines* Yes No In the past YEAR have you:Given family/friends more than $200* Yes No Re-paid loans to family/friends* Yes No Transferred any property to family/friends of more than $500* Yes No Lost more than $500 gambling* Yes No Been sued by anyone* Yes No In the past 90 DAYS have you:Gone on any vacations* Yes No Taken Cash Advances on Credit Cards* Yes No Bought any items worth more than $500* Yes No Given gifts of more than $200* Yes No Have you ever filed Bankruptcy before* Yes No Do you have any retirement accounts or investments* Yes No Are you the trustee or the beneficiary of any trust* Yes No Do you have any reason to believe you could file a lawsuit against someone else, whether or not you intend to pursue it* Yes No Do you expect any inheritances, life insurance, or other money or property from someone who has passed away (or who might pass away soon)* Yes No SpouseName* First Middle Last Date of Birth*Home Address* Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Best Phone Number To Reach You*Email* County of Residence*Have You Lived in Michigan For The Past 6 Months?* Yes No Members of your householdList all members of your household, their age, and what relation they are to you (this includes anyone who lives with you and shares income and expenses, even if not related):NameAgeRelation to you Employer*Occupation/Job Title*Length of employment*What is your Annual Salary or Hourly Wage*How often are you paid*WeeklyBi-weeklyMonthlyOtherDo you receive salary bonuses*Do you collect Social Security* Yes No Do you receive Alimony/Child Support* Yes No Do you receive Unemployment Compensation* Yes No How Much Do You Collect in Social Security Monthly?*How Much Do You Collect in Alimony/Child Support Monthly?*How Much Do You Collect in Unemployment Compesation Monthly?*List all income you received from ANY source not listed above(spouse) Do you owe any of the following:Income Taxes* Yes No Student Loans* Yes No Alimony/Child Support* Yes No Criminal Fines* Yes No (spouse) In the past YEAR have you:Given family/friends more than $200* Yes No Re-paid loans to family/friends* Yes No Transferred any property to family/friends of more than $500* Yes No Lost more than $500 gambling* Yes No Been sued by anyone* Yes No (spouse) In the past 90 DAYS have you:Gone on any vacations* Yes No Taken Cash Advances on Credit Cards* Yes No Bought any items worth more than $500* Yes No Given gifts of more than $200* Yes No Have you ever filed Bankruptcy before* Yes No Do you have any retirement accounts or investments* Yes No Are you the trustee or the beneficiary of any trust* Yes No Do you have any reason to believe you could file a lawsuit against someone else, whether or not you intend to pursue it* Yes No Do you expect any inheritances, life insurance, or other money or property from someone who has passed away (or who might pass away soon)* Yes No Real PropertyDo you own your home* Yes No What is the current value of your home*First Mortgage Company / Amount Owed*Second Mortgage Company / Amount Owed*Are you current on your mortgage payments* Yes No Has your Home been scheduled for a foreclosure sale* Yes No Do you wish to keep your home* Yes No Automobile #1Name on Title*Make and Model*Year*Date of Purchase*Month123456789101112Day12345678910111213141516171819202122232425262728293031Year202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920Lender / Amount owed*Mileage*Is this vehicle insured* Yes No Do you wish to keep this automobile* Yes No Do you have a second vehicle* Yes No Automobile #2Name on Title*Make and Model*Year*Lender / Amount owed*Date of Purchase*Month123456789101112Day12345678910111213141516171819202122232425262728293031Year202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920Mileage*Do you wish to keep this automobile* Yes No Is this vehicle insured* Yes No Please list your five largest Secured Creditors and the amount owed*A secured debt is any debt which is secured by some piece of collateral which could be taken to satisfy the debt. For example, a Home Mortgage or Automobile Loan.Creditor$ Please list your five largest Unsecured Creditors and the amount owed*An unsecured debt is any debt which is not secured by any collateral. Examples of these sorts of debts are credit cards, medical bills, personal loans, foreclosure/repossession deficiency.Creditor$ Mark any of the items listed below which pertain to you Medical Bills Repossession Lawsuits Loss of Job Wage Garnishment Bill Collectors Foreclosure/Eviction Utility Shutoff Credit Card Debt New job with lower income How did you hear about our firm* Yellow Pages Google Search Craigslist Yellowpages.com Referred by Attorney Referred by Friend You are a previous client Referred by the State Bar of Michigan Referred by the Grand Rapids Bar Association Other How did you hear about us?*
