Consultation Information Form

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

Call us today at: (479)877-2518

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