Potential Client Intake Questionnaire Please fill out our intake questionnaire as completely as possible. One of our attorneys will contact you in the event your case can continue. Today's Date (required) Referred by Did you purchase the vehicle in California? (required) ---YesNo--Stop, here. Name of Person on contract (required) Name of Co-Signer Main Phone # (required) Email (required) Date of Purchase (required) Make (required) Model (required) Vehicle Year (required) Mileage at Purchase (required) Vehicle ID Number (VIN) (required) Name of Car Dealer (required) Address of Dealer (required) Direct Loan or went thru Dealer (required) ---Direct LoanLoan thru DealerPaid Cash, No Loan Have you re-financed vehicle? ---YesNo Name of Finance Company Did you have a Trade-in? (required) ---YesNo Did Trade-in have a Lien Balance prior to trade in? (required) ---YesNo If yes, Please contact the trade-in bank and indicate the date the trade-in was paid off and for what amount. Are you still making monthly payments on the trade-in vehicle? ---YesNoNo trade-in Vehicle Did you make a down payment? (required) ---YesNo Down payment amount? (required) Method of Payment (required) CashCheckCredit CardOther If by Check(s), Did you Post Date it? ---YesNo What is Post Date(s)? (required) If more than one down payment was required, list DATES of payments and AMOUNTS Have you started making monthly payments for the vehicle? (required) ---YesNoNo, I paid cash. Monthly Payment Amount How many monthly payments have been made? Are your payments current? (required) ---YesNo Do you still have possession of the vehicle? (required) ---YesNo If no, please state reason: Is the vehicle operational? (required) ---YesNo Current Mileage (required) Prove you are human: What is 2 + 2?