Please print this form out before your consultation, if you can not get the form to print please call and we will email a copy to you.
BANKRUPTCY SERVICES of ARKANSAS & OKLAHOMA
REQUEST FOR NO-COST INITIAL CONSULTATION Date:________________
Name:________________________________________________________________________
First Last
Spouse’s name, if married:________________________________________________________
First Last
Address:______________________________________________________________________
Street City State Zip
If you have lived at your address less than three years, what was your prior address? Address:______________________________________________________________________
Street City State Zip
Cell#:___________ Home#:___________ Work#:___________
Email:_____________________ Place of Employment:___________________
Preferred Method of Contact: ◻️ Email ◻️Text ◻️ Cell ◻️ Home◻️Work
Preferred Method of Payment: ◻️ Cash ◻️ Check ◻️ Card* ◻️PayPal*
*Requires email and/or cellphone number. Subject to a transaction fee.
Are you a U.S. Citizen? ◻️ Yes ◻️ No If no, please explain: ___________________________
Have you filed for Bankruptcy before? ◻️ Yes ◻️ No Type ◻️Ch. 7 ◻️ Ch. 13
If yes, was your prior filing more than 8 years ago? ◻️ Yes ◻️ No
Number of dependents that reside with you in your home: ◻️ 0 ◻️ 1 ◻️ 2 ◻️ 3 ◻️ 4 ◻️ Other:
Do you rent or own a home? ◻️ Rent ◻️ Own
If you own a home, what is its estimated value? _____________
Approximate mortgage balance? ___________
Do you own any other real estate apart from your home? ◻️ Yes ◻️ No
Do you own and operate a farm? ◻️ Yes ◻️ No
Do you own any type of business in whole or in part? ◻️ Yes ◻️ No
If yes, what is the entity type: ◻️ Sole Proprietorship ◻️ Partnership ◻️ LLC/Corporation
What has been your average monthly household total income over the last 6 months?
◻️ $0-$2,000.00 ◻️ $2,000.00-$4,000.00 ◻️ $4,000.00-$6,000.00
Bankruptcy Services Of Arkansas & Oklahoma 