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.