Initial Eligibility Form for WNYLC Bankruptcy Clinic
Please fill out this form to help us determine your initial eligibility for WNYLC’s services. Please keep in mind that once you begin you must complete it in one sitting – if you exit out before submitting you will need to begin it again. You may find it helpful to take a look at all of the questions on the form before beginning so you can gather all necessary documents and information. If you have all your documents and information with you, the form should take approximately 45 minutes to complete. Please also note that WNYLC will not be able to determine your final eligibility for a Chapter 7 bankruptcy or our services until we have reviewed all your information.
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Email *
Basic information
Last name *
First name *
Preferred name
Street
City
State
Zip
Birth date
MM
/
DD
/
YYYY
Gender
Clear selection
Race
Clear selection
Ethnicity
Clear selection
Veteran Status
Clear selection
Pronouns
Mobile phone *
County of residence *
Martial Status
Clear selection
Dependents
Dependent 1's age/gender
Dependent 2's age/gender
Dependent 3's age/gender
Dependent 4's age/gender
Dependent 5's age/gender
Dependent 6's age/gender
Occupation (if unemployed, tell us your usual occupation) *
Gross household income from employment (in dollars) *
Do you or your spouse receive any income from sources other than employment? *
Required
If you checked a box other than "None" in the question above, please specify the amount for each item:
Have you lived at your current resident for the past 91 days? *
Have you taken cash advances on any credit cards in the last 90 days? *
Have you charged over $300 on any credit card in the last 6 months? *
Any prior bankruptcies?
Case number
Chapter 7 or Chapter 13
Clear selection
Date filed
MM
/
DD
/
YYYY
Location filed
Date of discharge/dismissal
MM
/
DD
/
YYYY
Inheritance (entitled to now or possibility within the near future?) *
Have you owned or had any interest in real estate (including timeshares) in the last 6 years? *
If you answered "Yes" in the question above, please indicate the address of the real estate:
Do you own automobiles, motorcycles, trailers, mobile homes, or other vehicles? *
If you answered "Yes" in the question above, please specify the Year, Make, and Model for vehicle 1:
If you answered "Yes" in the question above, please specify the Year, Make, and Model for vehicle 2:
If you answered "Yes" in the question above, please specify the Year, Make, and Model for vehicle 3:
Have you been involved in any type of litigation in the past 10 years or are you currently involved in one? *
How much debt do you have? *
What types of debt do you have? *
Any urgent problems? *
Required
How did you hear about us? *
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