Client Initial Worksheet

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LANPHIER & ASSOCIATES
CLIENT INTAKE SHEET

So we can better understand your present situation, please take a few minutes to complete the 1st two pages of this Worksheet. The more information we have about you, the better advice we can give you.

    Your First Name*
    Initial
    Last Name
    Suffix (Sr,Jr)
    Your Social Security No.

    Other Names / Business Names You’ve Used
    Gender
    Year of your Birth

    Your Street Address
    City
    State
    Zip Code

    Your Mailing Address (if different)
    City
    State
    Zip Code

    Your Home Phone
    Your Cell/Work Phone
    Your E-mail Address

    Who is your Current Employer ?
    Who was your Previous Employer ?

    Have you ever filed Bankruptcy (Chapter 7 or Chapter 13)? If so,
    YesNo
    When?

    Number of dependents living with you (not including your spouse)
    Marital Status
    Single (never married)MarriedSeparatedDivorcedWidowed

    * We need information about your spouse even if you are separated or they are not filing Bankruptcy with you.

    Spouse’s First Name
    Initial
    Last Name
    Suffix (Sr,Jr)
    Spouse's Social Security No.

    Other Names / Business Names Used by Spouse
    Gender
    Year of Spouse's Birth

    Spouse’s Street Address (if different)
    City
    State
    Zip Code

    Spouse’s Mailing Address (if different)
    City
    State
    Zip Code

    Spouse’s Home Phone (if different)
    Your Cell/Work Phone
    Your E-mail Address

    Who is Spouse’s Current Employer?
    Who was Spouse’s Previous Employer?

    Has your Spouse ever filed Bankruptcy (Chapter 7 or Chapter 13) ?
    YesNo

    INCOME Please list your income sources

    Your average Gross Paycheck per payday
    How often paid ?

    Average Takehome paycheck per payday

    Spouse’s average Gross Paycheck per payday
    How often paid ?

    Average Takehome paycheck per payday

    Self employed / Business Net profit per mo.

    Retirement / Pension / Social Security per mo.

    Other Income per mo.