WRITTEN CONSENT and INFORMATION FORM V4 with citizenship

WRITTEN CONSENT and INFORMATION FORM
Please provide the following information for our records. This will be available to attorneys employed by the Legal
Assistance Foundation of Chicago. Sometimes there are conflicts of interest.
Full Name: _________________________________________________________________________________________
Street Address: _____________________________________________________________________________________
City: _____________________________State:__________Zip Code:_______________ County:_____________________
Primary Phone:_______________________________Secondary Phone:__________________________________
E-Mail:__ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __
Please read the following and sign below.
The Bankruptcy Assistance Desk may provide short-term limited legal services to you regarding your bankruptcyrelated matter. The services are provided to you only at the time of your visit. The Assistance Desk Attorney will not
represent you. There will be no full or continuing legal representation of you in any capacity by the Assistance Desk
Attorney. Your visit will only provide short-term limited legal services and you should have no further expectations.
Assistance will be provided to you only after you acknowledge the following: I understand that the Bankruptcy
Assistance Desk may provide short-term limited legal services to me and that the attorney will not represent me in
any capacity in my matter. I have no further expectations other than receiving short-term limited legal services.
Signed:___________________________________________________________Dated:___________________________
The Help Desk Attorney MAY PROVIDE: bankruptcy
information, guidance in preparing documents,
assistance in accessing other information, references
to other legal services providers, and confidentiality
(unless you agree to disclosure).
The Help Desk Attorney WILL NOT: complete
paperwork for you (ALL documents are your own
responsibility), represent you in court or negotiate
with other parties for you, research or provide
copies of your court documents, or conduct
investigation into your case’s facts.
The Help Desk Attorney MAY DECLINE to advise you
if: you already have an attorney in your case, your
legal problem is beyond the scope of the Help Desk,
he or she has already given advice to an opposing
party, or it conflicts with the Illinois Rules of
Professional Conduct.
BE CAUTIOUS of legal advice given to you by others
in the waiting room. Everyone’s case is different
and legal advice given to someone else may not
apply to your case.
I hereby attest that I am a CITIZEN of the United States
Signed:
____________________________________________
I am not a US citizen. ____ Show your
documents to the attorney when you meet
PLEASE TURN OVER THIS PAGE AND COMPLETE THE FORM
Do you have a foreclosure sale today or tomorrow?
NO
YES
If you circled “Yes,” notify the attorney ASAP!
Are you a creditor or a debtor?
Creditor
Have you been to the Help Desk before?
Debtor
NO
How did you hear about the Help Desk?
Internet
I don’t know
YES
Friend/Family
Another office
Other_________
Why are you here today? ___________________________________________________________________
Debtor Information
Monthly Household Income $_____________________
Are your wages being garnished?
□ YES
Are you trying to keep your house? □ YES
Number in Household __________________
□ NO Has your driver’s license been suspended?
□ YES
□ NO
□ NO
□ YES
□ NO
Are you trying to keep your car?
Check types of debts you have and give approximate amounts:
□ Utilities
$________________
□ 2nd Mortgage or $________________
Home equity loan
□ Car Payment
$________________
□ Income taxes
$________________
□ Property taxes
$ ________________
□ Rent Payment
$________________
□ Payday loans
$_______________
□ Child Support
$________________
□ Traffic/parking ;ckets $_______________
□ Alimony
$________________
□ Medical bills
$_______________
□ Condo fees
$ _________________
□ Credit Cards
$_______________
□ Mortgage
$________________
FOR HELP DESK ATTORNEY ONLY
NOTES:
Case #:______________________M/F … AA/W/A/H/N.A./O .. D? … V?
Language: ________________
Do you have a foreclosure sale today or tomorrow?
NO
YES
If you circled “Yes,” notify the attorney ASAP!
Are you a creditor or a debtor?
Creditor
Have you been to the Help Desk before?
Debtor
NO
How did you hear about the Help Desk?
Internet
I don’t know
YES
Friend/Family
Another office
Other_________
Why are you here today? ___________________________________________________________________
Debtor Information
Monthly Household Income $_____________________
Are your wages being garnished?
□ YES
Are you trying to keep your house? □ YES
Number in Household __________________
□ NO Has your driver’s license been suspended?
□ YES
□ NO
□ NO
□ YES
□ NO
Are you trying to keep your car?
Check types of debts you have and give approximate amounts:
□ Utilities
$________________
□ 2nd Mortgage or $________________
Home equity loan
□ Car Payment
$________________
□ Income taxes
$________________
□ Property taxes
$ ________________
□ Rent Payment
$________________
□ Payday loans
$_______________
□ Child Support
$________________
□ Traffic/parking ;ckets $_______________
□ Alimony
$________________
□ Medical bills
$_______________
□ Condo fees
$ _________________
□ Credit Cards
$_______________
□ Mortgage
$________________
FOR HELP DESK ATTORNEY ONLY
NOTES:
Case #:______________________M/F … AA/W/A/H/N.A./O .. D? … V?
Language: ________________