CLIENT FORMS

Best Lawyer in Murfreesboro, TN

New Client Information Sheet

This form below will be used for your initial Information. It will be kept in this office for our office use only and will not be available to anyone outside this office. Thank you for your cooperation in answering these important questions. If you would like to download, print and fill out this form click here .

NEW CLIENT FORM

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SECTION 1: Please fill out the following information about yourself.

Date:

Referred By:

First Name:

Middle Name:

Last Name:

Date of Birth:

Social Security Number:

Marital Status:

Years Married (if applicable):

Address:

Dependents Living In Home:

How long at this address?

Home Phone:

Cell Phone:

Work Phone:

Best way to contact you?

Employer:

Job Title:

Employer Address:

Pay Rate:

How often are you paid?

Length of Employment:

Gross Pay Per Month:

Net Pay Per Month:

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SECTION 2: If you are married, please fill out the following information about your spouse. Skip section if you are not married.

First Name

Middle Name:

Last Name:

Social Security Number:

Cell Phone:

Work Phone:

Employer:

Job Title:

Employer Address:

Pay Rate:

How often is spouse paid?

Length of Employment:

Gross Pay Per Month:

Net Pay Per Month:

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SECTION 3: Please fill out the following information about your overall household.

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Other sources of income:

Social Security Ret/Dis/or SSI

Child Support:

Retirement/Pension:

Part-time Job:

Rental Income:

Co-tenant Contribution:

Food Stamps/ Fam First:

Other:

Do you owe for your house?

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If yes, please answer the following:

Who do you owe?

How much do you owe?

How much are the payments?

Does this include taxes and insurance?

How many payments behind are you (if any)?

Do you have insurance for your house?

Do you want to keep it?

Is a foreclosure pending?

Do you have a second mortgage?

If yes, who do you owe and how much?

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Please list the following information concerning any vehicles with loans against them:

VEHICLE 1:

Year, Make & Model:

Payments Behind (if any):

Is this vehicle insured?

Do you want to keep or surrender?

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VEHICLE 2:

Year, Make & Model:

Payments Behind (if any):

Is this vehicle insured?

Do you want to keep or surrender?

Do you own any vehicles clear of liens? (Autos, motorcycles, trailers, etc.)

If yes, please list make and model of each vehicle:

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OTHER SECURED DEBTS SUCH AS FINANCED LOANS:

Lender:

Amount Owed:

Items securing the debt:

Monthly Payment:

Do you want to keep or surrender?

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ADDITIONAL INFORMATION:

Are your wages being garnished?

If yes, by who?

Do you pay child support?

If yes, are you current on payments?

If no, how far behind are you?

Do you owe any debts to a former spouse?

Do you owe the IRS?

If yes, how much?

If yes, tax year(s)?

Do you owe any student loans?

If yes, how much?

Do you owe any debts co-signed by someone other than co-filing spouse?

Have you been sued by anyone or any company?

Are you suing anyone or any company at this time?

Do you have a claim for which you expect to receive payment (example - insurance, auto wreck)?

Do you expect to receive any inheritance or life insurance from anyone in the next 6 months?

Have you sold or traded or given away anything of value in the last 4 years such as a car or house?

615-895-6508

galen@galenpiercelaw.com

307 HICKERSON DR

MURFREESBORO, TN 37129

NEW CLIENT FORMS

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