Description
Provide a summary of the intake process up to the drafting of the Ch7 petition. Pay special attention to listing at least five important facts you as a paralegal would want to know (and make sure the attorney knows) from a potential client and why those facts are important. Use problem 4.5 (pg76) as your factual basis. fill out the intake below.
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LEGAL AID SOCIETY OF SAN DIEGO, INC.
.
BANKRUPTCY SELF-HELP CENTER
In person at Bankruptcy Court
Via zoom on my own device
Please fill out ALL information COMPLETELY. Thank you!
Are you at risk of
losing your home?
First Name:
Y N If so, please ask to see Fanny or Jacob when you finish this form.
Middle Name:
Last Name:
Date:
Other Names Used:
Phone:
Address:
Email
Address:
Zip
Code:
Alt Phone
number:
State:
Last 4 your Social Security number: X X X – X X – __ __ __ __
Your Race: _______________________
Your marital status:
Single
Hispanic/Latino_______
Married
Separated
Language:
Age:
Gender:
Non-Hispanic/Latino_________
Divorced
Including you, how many people live in your household? Just you
How many are children?
How many are veterans?
DOB:
2
Widowed
Other
3 4 5 or more
How many are seniors?
Name:
DOB:
Relationship:
Name:
DOB:
Relationship:
Name:
DOB:
Relationship:
Name:
DOB:
Relationship:
LIVING ARRANGEMENTS____________________________________________________________________________
Y N
How did you find out about the Self-Help Desk?
Online (Google) 211 Hotline
Legal Aid
Online (Court) Flyer
Friends/Family
Trouble paying rent/mortgage?
What is your monthly rent/mortgage?
Other ________ Online (LASSD)
Court
Saw Sign
Are there any adverse parties in your matter?
If Yes, List:____________________________
Y N
Online (Court) Flyer
Court
Permanent Resident ______
Are you a U.S. Citizen? Y N
Other Eligible Alien
______
Have you or anyone in household served in
the U.S. Armed Forces, including Reserves
and National Guard?
Y N
Do you have a lawyer? Y N
Updated
Updated 3/26/2020
11/01/2019
Physical and/or Mental None
Do you have a disability?
Please briefly describe why you are here:
Assets: Please put all bank accounts, property, and any other assets even if the value is zero:
INCOME
SOURCE
Hourly Rate/ Hours Per Week Gross Weekly
Gross Monthly
Assets
Asset Value
Do you believe that your household income is likely to change significantly (up or down) in the near future? Yes / No
If yes, how?_______________________________________________________________________________________
IMPORTANT: Please read and sign
I understand and agree that:
▪ Legal Aid Society and the attorneys at the Self-Help Clinic are not my attorneys unless a separate
retainer agreement is executed.
▪ I am representing myself with any matters discussed at the Self-Help Clinic.
▪ I may need to hire an attorney if the information I receive at the Self-Help Clinic does not resolve my
matter.
Today’s date
Your signature
I have already been to this Self-Help Clinic at least once before
Check any boxes
that apply to you:
I already filed for bankruptcy in the Past
If yes, List all dates of prior Bankruptcies
__________ __________ __________ __________
__________
I am not considering filing for bankruptcy
Have you called Legal Aid
for a Case Number?
Y N
How much money do you have in your checking account? (Estimate)
$
How much money do you have in your savings account? (Estimate)
$
How much do you have in your 401(k), or other retirement accounts? (Estimate)
$
0 1 2 3 or more
How many vehicles do you have?
Vehicle #1 :
Rev02232020
I own this vehicle without a loan
I lease
I have a loan (including title loans)
Year
Make/Model
Est. Value
Monthly Pmt.
Loan Balance
Months Behind
$
Vehicle #2 :
Year
$
I own this vehicle without a loan I lease I have a loan (including title loans)
Make/Model
Est. Value
Monthly Pmt.
Months Behind
Loan Balance
$
$
Have you lived in California for the last two full
years?
Y N
If not, what state previously?
Have you ever filed for bankruptcy?
Y N
Year:
Has anyone co-signed a loan for you?
Y N
Relationship:
Have you co-signed a loan for anyone?
Y N
Relationship:
Are you currently suing anyone?
Y N
For what?
Do you have any potential claims against anyone?
Y N
For what?
Is anyone suing you?
Y N
For what?
Chapter : 7 11 13
Have you owned a business in the past six years?
Y N
Does anyone have a claim against you for personal injury or death for driving while intoxicated?
Y N
Please list anything you own (besides vehicles), and estimated value: (if applicable)
Item 1:
Estimated Value: $
Item 2:
Estimated Value: $
Who do you owe money to?
Check all that apply. Please list approximate amounts.
Back child support/alimony: $
Money loaned by
Back income taxes:
Bank fees/overdraft
$
family/friends:
Store credit for
furniture/jewelry:
charges:
$
Past-due utility bills:
Bank loans/lines of credit:
$
Payday/check cashing loans: $
Credit cards:
$
Student loans:
$
$
Unpaid back rent:
Money you owe to anyone
$
Cash advances in last 70
days?
Charges in last 90 days?
Credit union loans:
Medical bills:
Updated
3/26/2020
Rev02232020
$
$
$
$
else:
$
$
$
$
LASSD Case Num:_______________________________
Legal Aid Society of San Diego, Inc. does not discriminate by reason of race, age, sex, sexual orientation, creed, color,
national origin, ancestry, religion, political affiliation, pregnancy, disability, marital status, medical condition, genetic
information, gender, gender identity, gender expression, victim of crime, military or veteran status.
CLIENT GRIEVANCE NOTICE: If you are dissatisfied with our services or because you were denied services, you may
contact the Administrative Offices of the Legal Aid Society of San Diego, Inc. at 1-877-534-2524, Ext. 1780. If you do not
reach a person at the time of your call, leave a message. Legal Aid Society of San Diego, Inc. will send you the proper
grievance forms for you to submit.
I am a citizen of the United States: _________________________________________ Date ____________________
APPLICANT DISCLOSURE: I agree that the Legal Aid Society of San Diego, Inc. may disclose any information on this
application to federal, state, local or private auditors of the Legal Aid Society of San Diego, Inc., or its subgrantees for any
purpose required by law who are also bound by the attorney-client privilege. We keep all documents for no more than 6
years. After that we may destroy the documents.
I certify that the above information is true, correct and complete to the best of my knowledge and belief.
APPLICANT’S SIGNATURE_______________________________________________ Date ____________________
YOU ARE DONE! ☺
PLEASE RETURN THIS FORM BY ONE OF THE FOLLOWING
METHODS TO LEGAL AID:
Mail: Legal Aid Society of San Diego
110 South Euclid Ave.
San Diego, CA 92114
Email: [email protected]
Fax: 619-263-5697
Updated
3/26/2020
Rev02232020
STOP
OUR VOLUNTEERS WILL
COMPLETE THIS SECTION
Reasons for visit: (check all that apply)
Adversary proceeding
Amending bankruptcy forms
Chapter 13 bankruptcy
Relief from stay
Loan modification
Petition preparer fraud
Attorney misconduct
Case dismissed
Debt collection/creditor harassment
Eviction
Proof of claim
Reaffirmation agreement
Case closed without discharge
Chapter 7 bankruptcy
Foreclosure
Identity theft
Petition review before filing
Other:
Volunteer notes:
Assistance/services provided:
Was their home in jeopardy in any way? Were you able to suggest anything to help them keep it?
What?
Yes No House not in jeopardy.
Explain: ________________________________________________________________
Referral to:
Legal Aid Society of San Diego, Inc.
SDCBA Lawyer Referral and Information Service
Attorney Referral List provided to him/her
Pro Bono Counsel
Plans to hire an attorney (other than one we referred them to)
No referral – will proceed pro se with case in Bankruptcy Court
No referral – will not proceed with case in Bankruptcy Court
Not sure what to do
Will do nothing
Other____________________________________________
Volunteer Name:
Updated
3/26/2020
Rev02232020
______________
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