Michael J. Rose PCIntake Sheet - Michael J. Rose PC

INTAKE SHEET FOR MICHAEL J ROSE PC

4101 Perimeter Center Drive, Suite 120

Oklahoma City, OK 73112

(405) 605-3757 telephone

(405) 605-3758 facsimile

mikeroselaw.com

Information provided by you STAYS IN THIS OFFICE and will be kept ABSOLUTELY CONFIDENTIAL.

All information will be shredded after six months if you do not file a case with our office.

Appointment Date

Your Name*

First Last

Your Age*

Your Spouse

First Last

Spouse Age

Address*

Street Address Address Line 2 City State Zip

Your Email*

Spouse Email Address

Your Home Phone

Your Mobile Phone*

Employment Info

Your Employer*

Your Job Description

Your Work Phone*

Your Monthly Gross

Spouse Employer*

Spouse Job Description

Spouse Work Phone

Spouse Monthly Gross

Total Monthly Gross Pay

Do you earn money from self-employment of any kind? Please explain:

Number of Defendants and Ages:

Home Mortgage

If you have one (or more) home mortgages, land or mobile home payments, list them here.

Mortgage Creditor

Mortgage Balance Owed

Mortgage Monthly Payment

Mortgage Amount Behind

Second Mortgage Creditor

Mortgage Second Balance Owed

Mortgage Second Monthly Payment

Second Mortgage Amount Behind

Vehicles

If you own cars, trucks, tractors, motorcycles, RV's, boats, jet skis etc. list them below.

Vehicle 1 Make Model

Vehicle 1 Creditor

Vehicle 1 Amount Owed

Vehicle 1 Monthly Payment

Vehicle 1 Amount Behind

Vehicle 2 Make Model

Vehicle 2 Creditor

Vehicle 2 Amount Owed

Vehicle 2 Monthly Payment

Vehicle 2 Amount Behind

Vehicle 3 Make Model

Vehicle 3 Creditor

Vehicle 3 Amount Owed

Vehicle 3 Monthly Payment

Vehicle 3 Amount Behind

Tax and Child Support Debts

If you owe taxes, or if you are past due on your child or spousal support, list below.

Debt 1 Creditor

Debt 1 Balance Owed

Debt 1 Monthly Payment

Debt 1 Amount Behind

Debt 2 Creditor

Debt 2 Balance Owed

Debt 2 Monthly Payment

Debt 2 Amount Behind

Unsecured debts

Number

Have you ever filed for bankruptcy relief?

If so, when?