Client Intake - Short Form

Personal Information











Landlord or Mortgage Holder's Information







Additional Creditor Information


Have you ever filed bankruptcy before?

Are you being evicted?

If you have any questions while completing this, Please call customer service at 800-200-4384.

Disclosure: The Law Offices of Eugene Ahtirski is a debt relief agency assisting in debt negotiation and bankruptcy.
Initial consultation does not include becoming attorney of record.