Client Questionnaire

 

Roderick H. Martin & Associates, P.C.

279 Washington Ave.

Marietta, GA 30060-1980

770.427.5853

Client Questionnaire                                          Date ญญญญญ__________

 

The Client is not entitled to a free consultation unless the information provided herein is true and complete.  By filling out this form and giving it to Roderick H. Martin & Associates, P.C., client is declaring the information herein to be truthful.  If you decide to petition the court this information will be a matter of record and therefore must be accurate.

 

Full Name:          Last ______________________ First _____________________ Middle ______________

 

Address:              __________________________________________how long here______

 

City:                      _________________State: _______Zip: _______County: _____________

 

Date of Birth       ___ /___ / ______         Social Security Number __ __ __-__ __-__ __ __ __

 

Have you ever used any other name(s)? if yes list other names: _________________________

 

Cell Phone             _________________ Work Phone: ______________Other _____________

 

EMAIL Address:__________________________________________________________

 

If you have a different mailing address, please list:

 

Mailing Address: ______________________________________

 

City:                          ________________State: ________Zip: _______County: _____________

 

Spouse

 

Full Name:          Last ______________________ First _____________________ Middle ______________

 

Address:              __________________________________________how long here_______

 

City:                      _________________State: _______Zip: _______County: ______________

 

Date of Birth       ___ /___ / ______         Social Security Number __ __ __-__ __-__ __ __ __

 

Have you ever used any other name(s)? if yes list other names: _________________________

 

Cell Phone             _________________ Work Phone: ______________Other _____________

 

EMAIL Address:__________________________________________________________

 

Marital Status:       Married □   Single □   Divorced □   Separated □   Widowed □

 

Age of dependents:   Son: ______________ Daughter: _______________ Other: _________________

 

Are you aware of any pending foreclosure actions, repossessions, or other lawsuits?  □ Yes / □ No

 

Have you applied for a Loan Modification?  □ Yes  /  □ No       Date: __________

 

Have you filed a bankruptcy in the last eight years?  □ Yes  /  □ No     File Date: _________

 

How did you hear about our Law Firm?  __________________________

 

 

Current Income:

Your Income                                                                     Spouse Income

 

Occupation: _________________________	Occupation: _________________________
Employer:    _________________________	Employer:    _________________________
Address: ___________________________	Address: ___________________________
How Long: __________________________	How Long: __________________________
Other Income: _______________________	Other Income: _______________________
Income for year 2008   ________ 2009______	Income for year 2008   ________ 2009______

                 

Do you receive any of the following:                                   Does your spouse receive any of the following:

Alimony?	Yes □    No □	Alimony?	Yes □    No □
Amt. per mth.	$ _________	Amt. per mth.	$ _________
Child Support?	Yes □    No □	Child Support?	Yes □    No □
Amt. per mth.	$ _________	Amt. per mth.	$ _________
Income from real estate?	Yes □    No □	Income from real estate?	Yes □    No □
Amt. per mth.	$ _________	Amt. per mth.	$ _________
Social Security?	Yes □    No □	Social Security?	Yes □    No □
Amt. per mth.	$ _________	Amt. per mth.	$ _________
Disability?	Yes □    No □	Disability?	Yes □    No □
Amt. per mth.	$ _________	Amt. per mth.	$ _________
Retirement/Pension?	Yes □    No □	Retirement/Pension?	Yes □    No □
Amt. per mth.	$ _________	Amt. per mth.	$ _________
Government Assistance?	Yes □    No □	Government Assistance?	Yes □    No □
Unemployment, Food Stamps, etc.	$ _________	Unemployment, Food Stamps, etc.	$ _________

                                                                                   

                                              

Personal Property: Check (Yes) or (No) & fill in description, location and value.

 

Type of Property	Do you have any? Yes   No	Description and Location	Value $
Checking Account	Yes □   No □
Savings Account	Yes □    No □
Sports, photographic, hobby equipment, firearms	Yes □   No □
Interest Insurance policies (term, universal, whole life)	Yes □   No □
Interest in IRA, 401(k), 403(b), TRS, etc.	Yes □   No □
Stock & Interests in incorporated business or sole proprietorship	Yes □   No □
Inheritance	Yes □   No □
Tax Refunds or other monies owed to you	Yes □   No □
Other contingent claims, (Workers Comp or Personal Injury Cases)	Yes □   No □
Boat,  Motor Home,  Motorcycle, ATV and Accessories	Yes □   No □
Timeshares	Yes □   No □

 

 

Current Expenses:

 

The following questions ask for your expenses each month. If you are unsure of the amount you pay each month, but know the amount for a different period (per day, week, year etc.) write in the amount and the frequency that you pay for that item.

 

 

First or Primary Mortgage	$ _________
Second Mortgage or Home Equity Line of Credit	$ _________
Rental  (Home, Apartment, Condo, Townhouse)	$ _________
Property  Insurance (If not included in mortgage) Real Estate Taxes      (If not included in mortgage)	$ _________ $ _________
Gas & Electric (Heating & Air) Water & Sewage	$ _________ $ _________
Alarm $_____ Cable $_____ Internet $ _____ Lawn $ _____ Pest Control $ _____ Trash $_____ Home Phone _____ Cellular Phone $_____ Total Utilities	$ _________
Home Maintenance	$ _________
Groceries	$ _________
Clothing/Uniforms	$ _________
Laundry & Dry Cleaning	$ _________
Medical, Dental , Vision (out of pocket expenditures)	$ _________
Transportation (gas, parking, tolls etc.)	$ _________
Personal Grooming (haircuts, toiletries etc.)	$ _________
Charitable /Contributions (must be documented)	$ _________
Insurance not deducted from pay check Homeowner/Renter. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Health . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Life . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. . . . . . . . . . . Disability. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Auto. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .	$ _________ $ _________ $ _________ $ _________ $ _________
Alimony / Child Support	$ _________
Home Owners Association Fee	$ _________
Children’s child care, school lunches, activities, after school programs	$ _________
Unreimbursed business expenses	$ _________
Other (Pet expenses, membership dues, etc.)	$ _________

                                                        Total Monthly Expenses      $ _________

 

 

 

Debts:

 

Type of Debt	Creditor Name/Collection Agency	Amount Owed
Mortgage:	_________________________	$___________
2nd Mortgage:	_________________________	$___________
Unpaid Rent:	_________________________	$___________
Loans:	1.________________________	$___________
(Banks, Credit Union,	2.________________________	$___________
Signature Loan)	3.________________________	$___________
Student Loans:	1.________________________	$___________
	2.________________________	$___________
Vehicle(s):	1.________________________	$___________
	2.________________________	$___________
	3.________________________	$___________
Unpaid Alimony/	__________________________	$___________
Child Support:
Unpaid Taxes:
Federal	__________________________	$___________
State	__________________________	$___________
All Other Unpaid Debts:	1._________________________	$___________
(Credit Cards, Medical Bills	2._________________________	$___________
Estimated amount owed)	3._________________________	$___________
	4._________________________	$___________
	5._________________________	$___________
	6._________________________	$___________
	7._________________________	$___________
	8._________________________	$___________
	9._________________________	$___________
	10.________________________	$___________
Unpaid Service Fees
(Attorneys, Accountants,	__________________________	$___________
Etc.)
	Total Debts This Page	$___________