JavaScript isn't enabled in your browser, so this file can't be opened. Enable and reload.
Warren Brumel, Esq. - New Client Information
Please take a few moments to complete this questionnaire to allow us to serve you better and quicker.
Sign in to Google
to save your progress.
Learn more
* Indicates required question
Your first and last name
Your answer
Marital status
*
Single (never married)
Married
Divorced
Widowed
Separated
Civil union
Other:
If married, your spouse's name
First and last name
Your answer
Best email addresses for us to use to contact you (and your spouse):
*
Your answer
Best phone numbers for us to use to contact you (and your spouse):
*
Your answer
Home address (full mailing address):
*
Your answer
How did you learn about our office?
*
referred by attorney/accountant/realtor
referred by past or present client
you were previously a client
Google or other search engine
Facebook
Billboard or other ad
AVVO, NACBA or Lawyer.com or other lawyer referral site
Podcast / radio ad
Other:
Required
Are you employed?
*
Yes
No
Required
If you are employed, tell us the name of your employer, your job title, and how long you have worked there.
Your answer
Is your spouse employed?
Yes
No
Clear selection
If your spouse is employed, tell us the name of their employer, their job title, and how long they have worked there.
Your answer
Do you or your spouse have income from any source other than wages, earnings or business operations?
*
No income other than wages/earnings
Social Security
Unemployment
Disability
Pension
Workers comp
Child support/alimony
Other:
Required
Do you own or rent your residence?
*
Own
Rent
Live with parents/relatives/other
Other:
Required
If you own your home, is it a
one family home
condo/townhome
duplex or two family
mobile home
Other:
Clear selection
If you OWN your home, what year did you buy it and what was the purchase price?
Your answer
If you OWN your home, how much do you think you could sell it for today?
Your answer
What is the total balance due and the monthly payment on your main home mortgage?
Your answer
What is the total balance due and the monthly payment on your second mortgage including home equity lines of credit?
Your answer
Are you current in making your mortgage payments?
Yes
No
Maybe
Clear selection
If you do NOT own real estate at this time, did you ever?
Yes
No
Other:
Clear selection
What vehicles do you own or lease? Tell us the year, make, model and miles for each vehicle.
Your answer
Are you current in your auto loan/lease payments?
Yes
No
Clear selection
Has anything of yours been repossessed, seized, levied or garnished in the last year?
Yes
No
Clear selection
Have you filed for bankruptcy relief in the past 20 years?
Yes
No
Clear selection
What is your weekly gross (before deductions) wages?
Your answer
What is your spouse's weekly gross (before deductions) wages?
Your answer
How many members are in your household (that you support), including yourself?
Your answer
How much money do you have in checking, savings or credit union accounts?
Your answer
NOT including retirement accounts, do you have any stocks, bonds, mutual funds, Certificates of Deposit or other investments?
Yes
No
Clear selection
Do you have a pension, 401k, IRA or other retirement account?
No
Yes, through my present employer
Yes, through a prior employer
Yes, I have an IRA, SEP or other account NOT through an employer
Other:
Do you have any student loans?
Yes
No
Maybe
Clear selection
About how many different creditors do you owe money to, including credit cards, medical, loans, mortgages and car loans?
*
Your answer
What is the total amount of your credit card, medical and personal loan debt (NOT including student loans, mortgages or auto loans)?
Your answer
Do you own a time share, boat, jewelry, collectibles, artwork or anything else that you could sell and net over $1000?
Yes
No
Clear selection
Are you currently owed a tax refund?
Yes
No
Clear selection
Do you have any law suits or claims you can make against anyone for personal injury, worker's comp, breach of contract, property damage, malpractice, discrimination, etc. where you might collect money in the future?
Yes
No
Maybe
Clear selection
Have you sold, given away, gifted or otherwise transferred real estate or anything else of value in the last four years?
Yes
No
Clear selection
Have you filed all required tax returns for the past four years?
Yes
No
Not sure
Clear selection
Submit
Clear form
Never submit passwords through Google Forms.
This content is neither created nor endorsed by Google.
Report Abuse
-
Terms of Service
-
Privacy Policy
Forms
