Michael Barnett, PA law Office

Michael Barnett, Esq. Main Office & Mailing Address: Tampa (813) 870-3100

Board Certified -- 106 S. Armenia Ave. Lakeland (863) 648-4064

Consumer Bankruptcy Law -- Tampa, FL 33609-3308 Dade City/San Antonio (352) 521-0190

American Board of Certification Appointments also available at: Elsewhere (800) 393-3100

Dade City: 38100 Meridian Ave., Dade City Facsimile (813) 877-4039

www.tampabankruptcy.com Lakeland: 215 Imperial Blvd., Ste B-1 mpa7@tampabay.rr.com

New Client Information Sheet

Date:

Name: Social Security # Present

Address: City:

Telephone: Home Work Zip

Employers Name and Hourly/monthly/annual salary:

Name of Spouse: Social Sec. # Present

Spouse's Employer: Telephone:

Spouse pay Client Email address

PLEASE FILL OUT COMPLETELY, estimate amounts if you are not sure

Real Estate owned: Address:

Mtg. Co. payoff mo pmt value months now due

1st

mtg

2nd

mtg

Do you own any other real estate?

Automobiles, boats, 4 wheelers, etc., whether you owe on them or not Make, model monthly months

& year Loan Co payoff pymt value now due

1st

veh

2nd

veh

Have you given any creditors a list of your furniture when you

borrowed money from them? If so, list these creditors:

Have you financed any furniture, electronics, jewelry or appliances through any creditors that you still owe money to?

Do you owe money to: (if yes, put amount owed, and to who)

Alimony ________

Child Support ________

Student Loans _______

Do you owe money to the IRS? If so for each year show the year the taxes are owed for, when the return was filed, and when the tax return was due (ie usually due 4/15 of the following year, later if an extension was requested). If you do not have this information now, you can estimate but note that it is an estimate.

Taxes owed due for year

Taxes owed due for year

Have you filed all tax returns due?

For the 2010 return: did you get a refund or owe? _____

List major unsecured debts: (estimate amounts owed)

When did you last charge anything on a credit card?

When was the last cash advance on a credit card? _______

What is the total amount charged plus total cash advances on all

Credit cards for the last 2 months $_____ for the last 6 months $ (do not include interest or late charges for the above line)

name of creditor amount owed name of creditor amount owed

Do you owe any money to relatives?

Have you repaid any loans to relatives the last 2 years? ____

If so, to who and how much

Have you made any gifts to family or friends of items worth more than $500 in the last 2 years?_____ If so to who and what _______________

Have you transferred any cars, land, or anything else worth more than $500 from your name to anyone else in the last 2 years? ______

If so to who and what? ___________________

Are you suing anyone, or do you have the right to sue anyone?

If you have any type of pension, retirement plan, profit sharing plan, stock option plan, or annuity: put down name and approximate

amount of money in plan here:

Other than furniture, clothes & jewelry, do you have anything else worth over $250.00

Hhg/clothg/jewly <

Where did you hear about this office:

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(2) Notes:

(3) Special Instructions:

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