Name

Phone Number

Please select the nature of your legal matter: Please select the nature of your legal matter:Personal InjuryWorker's CompensationBusiness LawEstate PlanningReal Estate LawEmployment LawBankruptcy

Date of Incident

Location of Incident

Other Party(s) Involved

Have you received treatment for your injury? (if applicable) Have you received treatment for your injury? (if applicable) Yes No

Why do you wish to file bankruptcy?

Do you wish to file as an individual, business or both? Do you wish to file as an individual, business or both? Individual Business Both

Please list your approximate income and your approximate expenses (monthly).

Please list your approximate assets and your approximate debts.

Date of Incident

Location of Incident

Name of Employer

How long were you employed?

Were you injured while working? Were you injured while working? Yes No

Were you an employee? Were you an employee? Yes No

Did you report the incident to your employer? Did you report the incident to your employer? Yes No

Have you received treatment for your injury? Have you received treatment for your injury? Yes No

Did you miss work? Did you miss work? Yes No

Do you have an open claim? Do you have an open claim? Yes No

Name of Employer

How long have you been employed?

Are you a W2 employee? Are you a W2 employee? Yes No

Were you fired, demoted or disciplined? Were you fired, demoted or disciplined? Fired Demoted Discplined

What date?

Reason given by employer

Had you received prior discipline, warnings or poor performance reviews? Had you received prior discipline, warnings or poor performance reviews? Yes No

Why do you believe you were discriminated against and/or retaliated against?