Bankruptcy intake form

Teel & Gay, P.L.C.
Please enter all information requested, and don't forget to click send at the end.
Your Last Name (*Required)*
Your legal first name
Your birthdate*
Your other names used (maiden name, other last names, etc.)
Your E-mail*
Your cell number*

Area CodePhone Number
Your spouse's last name (if considering filing)
Your Spouse's legal first name (if considering filing)
Your spouse's birthdate (if considering filing)
Your spouse's other names used
Husband's Full Name (if considering filing)

First NameLast Name
Wife's Full Name (if considering filing)

First NameLast Name
Spouse's email if applicable
Spouse's cell

Area CodePhone Number
Physical Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry
Mailing address if different

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry
What county do you live in?*
Home phone or another number where we can reach you

Area CodePhone Number
Have you lived in West TN for at least 6 months?
If no, have you lived in West TN for at least 91 of the last 180 days?
Marital Status*
Are you a cosigner on any loans or do you have a cosigner on your loans?
Do you owe the IRS?
How many people live with you that you are financially responsible for? Include yourself in this number.
Where you live, do you rent, own your property, or live with someone else?
How many pieces of property (land) have your name on them?
How many mortgages do you have?
Is your house up for foreclosure?
Do you owe land taxes?
Are there any cars that have your name on the title?
How many cars have your name on the title?
Year, make and model of first car (ex. 2009 Chevy Malibu)
Car 1 - is there a loan on it?

YesNo
Car 1 - Is it up for repossession?

NoYes -- they are looking for itYes -- it is already repossessed
Year, make and model of second car (ex. 2009 Chevy Malibu)
Car 2 -- Is there a loan on it?

YesNo
Car 2 -- Is it up for repossession?

NoYes -- they are looking for itYes -- it is already repossessed
Year, make and model of third car (ex. 2009 Chevy Malibu)
Car 3 -- Is there a loan on it?

YesNo
Car 3 -- Is it up for repossession?

NoYes -- they are looking for itYes -- it is already repossessed
Additional cars: please list year, make, model, whether there is a loan, and whether it is up for repossession
Do you have any rent or lease to own loans?
Do you have student loans?
Is anyone suing you?
Is your paycheck being garnished?
Have you sued anyone in the last year, or do you think you might have a claim against anyone for any reason?
Have you gotten any loans in the last 3 months?
What are your sources of income? Check ALL that apply.

workunemploymentsocial securityworkers comp incomefood stampschild support or alimonyannuityretirement (not social security) or pension incomeother income
If you are employed, what is the name of your employer?
How often are you paid by your employer?
If your spouse is employed, what is the name of your spouse's employer?
How often is your spouse paid by his/her employer
Household goods section: We have listed categories and rooms in your house. Please think about those rooms and how much money you would get if you sold those items at a yard sale. Please do not list the amount you paid, or that you would accept. Instead, list the amount you would actually get if you sold it at a yard sale.
Household goods and furnishings. Examples: Major appliances, all furniture, linens, china, kitchenware*
Electronics. Examples: Tvs, radios, computers and related items, music collections, electronic devices including cell phones (but not leased cell phones), cameras, media players, games, game consoles, etc. *
Please give a total value of the TVs you own, if any. *
Please give a total value of the media players you own, if any. This includes DVD, Blu-ray, VHS, etc. *
Please give a total value of the radios you own, if any. *
Please give a total value of the computers, tablets, and related equipment you own, if any. *
Please give a total value of the physical music you own, if any. This would include cd's, vinyl, etc.*
Please give a total value of the physical movies you own, if any. This would include dvd, Blu-ray, etc.*
Please give a total value of the cameras and related equipment that you own, if any.*
Please give a total value of the video game consoles, video games, and related equipment that you own, if any.*
If you have a cell phone, is it leased or paid for?*

leased (make payments on it)paid forI have more than one phone, and some are leased and some are paid for
If your phone is paid for, what is it worth? If you have more than one paid for phone, add them together and give us the total. Do not include the value of any phone that is leased or on which you make payments.
Please tell us about any other electronic items that you own that have not already been valued, and specifically tell us what those things are and the value of each.
Collectibles of value. Examples: Antiques and figurines, paintings, prints, other artwork, books, pictures, other art objects, stamp coin or sports card collections, other collections, memorabilia and collectibles.
Collectibles of value. Examples: Antiques and figurines, paintings, prints, other artwork, books, pictures, other art objects, stamp coin or sports card collections, other collections, memorabilia and collectibles. Please specifically list those collectible items you own, and the value of each one.*
Equipment for sports and hobbies. Examples: Sports, photographic, exercise and other hobby equipment; bicycles, pool tables, golf clubs, skis; canoes and kayaks, carpentry tools not used in business; musical instruments, hunting equipment (excluding weapons).*
Please specifically list those items you included in the sports and hobby value.
Firearms. Examples: pistols, rifles, shotguns, ammunition and related equipment, bows and related equipment.*
Clothes. Examples: everyday clothes, furs, leather coats, designer wear, shoes, accessories.*
Wedding rings. Exclude all other jewelry for this line. *
Jewelry. Examples: everyday jewelry, heirloom jewelry, watches, jems, gold, silver. Exclude wedding rings only. Include all other jewelry.*
Non-farm animals. Examples: dogs, cats, birds, horses. *
Any other personal and household items you did not already list, including any health aids you did not list. *
Any other property in your house that isn't listed in another category.
How did you hear about us? check all that apply

A friend or coworkerinternettvradiofacebook
How did you hear about us?*
I understand that submitting this form does NOT create an attorney - client relationship, and that nothing on this form is considered legal advice. *

Yes
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Teel & Gay, P.L.C.