Section C: Information about your Legal Matter please check all boxes that apply.
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Debt Collection Foreclosure Auto Insurance Subrogation Structured Settlement Transfer
Debt Collection
1. What company or companies say that you owe them money?
2. Have you been sued on this debt?
Yes No
a. What is your court case number (if known)?
3. Do you have any notices or court papers related to this problem?
Yes No
4. Have you had any contact with the company suing you or their attorney?
Yes No
a. What was said?
5. Do you believe this debt is the result of identity theft?
Yes No
Please explain.
6. Do you believe this debt is the result of someone else using your account?
Yes No
a. Please provide the person’s name and date of birth.
7. Do you disagree with the amount they say you owe?
Yes No Please explain.
8. When did you last make any payments or use the account?
9. What caused you to fall behind on payments?
Detailed income and financial information
1. What is your gross income?
Please note amount and frequency.
2. What is your net income?
3. What is the source of your income? Ex: employment, Social Security, benefits (Food Stamps, etc.)
4. Do you have any bank accounts?
Yes No
5. Do you own a car, a home, or other major assets?
Yes No
a. What assets do you own? Please describe.
6. Can you afford to make any payments toward this debt?
Yes No
a. What do you think you can afford?
7. What else should we know about this debt? (Ex: Any concerns with identity theft, issues with how you got the account, medical and/or financial hardship preventing you from being able to pay, etc.)
8. What is your goal? (Ex: get an affordable payment plan, dispute that you owe the debt, stop garnishment, etc.)
9. Is there anything else we should know about your case?
Foreclosure
Home
1. Have you been sued for foreclosure?
Yes No I don't know
a. Have you received any notices on D.C. Government letterhead talking about foreclosure and mediation? Yes No
2. Do you have any deadlines coming up?
Note: If you already described this deadline to us earlier in the intake, you do not need to do so again.
3. What is the address of the home that is in danger of foreclosure?
4. Do you live in the home facing foreclosure?
Yes No
5. Who else lives there?
Please enter names and dates of birth, if known, of anyone else living there. This information is required for conflict check purposes.
6. Do you have any tenants?
Yes No
Please provide the names and dates of birth of all tenants.
7. Who owns the home (i.e. who is on the deed)?
8. Is your home part of a condominium or homeowners’ association?
Yes No
What is your current monthly condo or HOA fee? Yes No
9. Do you own any other properties?
Yes No
a. Please provide the address(es) for any other property/properties that you own.
Mortgage
1. Who is your mortgage company?
2. Please provide basic information about the loan at issue:
a. Who is the named borrower on the loan? FHA Fannie Mae Freddie Mac Not sure
d. When was the last time you made a payment on the mortgage? Please provide an estimate if you are not sure. Yes No
When?
3. Do you currently have any other mortgages or lines of credit on the property?
Yes No
Please provide the name of the lender and estimated balance for the other loan(s).
Detailed income information
1. For each person in your household (including yourself), please list their gross income
(amount and frequency) and the source.
Name
Gross Income (ex: $1200/mo)
Source (ex: employment, food stamps, rent payments)
2. Are you able to document all of the income in the household (through paystubs, benefits letters, tax returns, etc.)?
Yes No
3. Is any income expected to change?
Yes No
Please explain:
Goals
1. Do you want to keep the home, sell it (is the property already listed?), or do something else with it?
2. Is there anything else we should know about your case?
Auto Insurance Subrogation
Please fill out the below questions if you were involved in an auto accident and the other driver’s insurance company is demanding money/reimbursement from you because they claim you were at fault. If this does not describe your situation, please call Legal Aid’s intake line at 202-628-1161.
A. Court Case
1. Have you been sued by the other driver’s insurance company?
Yes No
a. What is your court case number?
2. How did you find out about the case?
3. Has your driver’s license been suspended?
Yes No B. The Accident
1. Please describe what you remember about the accident (if possible include the date, location, who was driving, who else was in the car, and what happened.)
2. Who do you think was at fault and why? (If you think more than one person was at fault, please explain.)
3. Did the police or other first responders come, or were there any other witnesses?
Yes No
a. Please explain.
4. Have you been interviewed by anyone about the accident (for example, the insurance company)?
Yes No
a. Please state who you spoke with and describe what was said.
C. Insurance and Vehicle Information
1. Did you have auto insurance at the time of the accident?
Yes No
2. Were you the owner of the vehicle involved in the accident?
Yes No
a. Who was the owner (for example, if you were driving a friend or family member’s car or an employer’s vehicle)? Yes No Not Sure
D. Goal
1. Please describe your goal in resolving this case (for example, get affordable payment plan, get driver’s license back, dispute whose fault the acciddent was, etc.)
2. Is there anything else we should know about your case?
Structured Settlement Transfer
Please fill out the below questions if you have a structured settlement annuity and are in the process of selling your right to future payments in exchange for lump sum cash now. If this does not describe your situation, please go back and select another type of case, or call Legal Aid’s intake line at 202-628-1161.
A. Proposed Transfer
1. What is the name of the company proposing to purchase your structured settlement annuity payments?
2. How much money are you trying to get paid for the transfer?
3. Please explain why you need the money from the transfer.
4. Did the company reach out to you to do the deal? Or, did you reach out to them? Please describe.
5. Did you negotiate with the company or shop around to get a better deal?
Yes No
a. Please explain.
6. Please describe your understanding of the proposed transfer (for example, what you are selling and how much you are getting in return).
7. Has the company filed paperwork asking the court to approve the transfer?
Yes No Not Sure
a. What is your court case number?
Background on Your Structured Settlement Annuity
1. Please describe the underlying case that resulted in you getting an annuity (what type of case was it, where was it filed, when did it settle, etc.)
2. What was the case name and case number?
3. Please describe the current structure of your annuity payments (for example, describe any monthly amounts or lump sums that you are supposed to receive).
4. Have you ever tried to transfer your annuity payments before now?
Yes No
a. Describe any prior transfers (include dates and court case numbers, if any; the company that did the prior transfer; and note whether the prior transfers were approved)
Financial information
1. Please list all of your sources of income (including all public benefits) and the amount/frequency
Source
Amount/Frequency
2. Do you have any dependents?
Yes No
a. Please list your dependents and their relation to you.
3. Do you depend on anyone else financially?
Yes No
a. Please explain.
Is there anything else we should know about your case?
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