Free Bankruptcy Consultation

Optional New Client Form

This short form is totally optional. We can also get this information over the phone if you would rather call us. But if you want, you can fill this out and forward it to us and we will know quickly if you appear to be a good candidate for bankruptcy relief. If so, we will be happy to schedule your appointment in our Des Moines Office.

Note: Jeff does respond to these forms on evenings/weekends as time allows, so feel free to send it to us at any time.

This form is useful for Iowa Residents Only.

Name		Email
Phone: (optional)
Iowa county of Residence:
Gross Annual Family Income: (Include wages, child support, business income etc.)
Number of people in your household:

Please note any changes to income in the last 6 months:

How much credit card use in the last 90 days?
(Include balance transfers and cash advances)

Describe amount and reason for any payments to family in the last year:

Describe any lawsuits or claims you have against others:

If you have a business or significant assets/investments that you want to keep, describe:

If you are expecting a large tax refund, please note estimated amount:

What specific questions do you have for Jeff:

For your first appointment you will need:

• $1,199 in cash or money order
• Credit Counseling Certificate
• Copies of all bills you intend to discharge and copies of any collection letters
• Creditor contact information (address, account #’s) on debts you will keep
• Last two months pay stubs from work (including your spouse even if they are not filing)
• W2's for the last two years
• If you do not receive wage income, bring records of other income for the last six months
• Most recent state and federal tax returns
• Legal Description of your home if you own
• Proof of valuation of your home such as tax or other appraisal if you have them
• Photo ID and Social Security Card or proof of social security number
• Both Husband and Wife must attend if you are filing a joint bankruptcy

Thanks!
We look forward to helping you get a fresh financial start!
— Jeff Mathias