Section I - Personal and Contact Information:

Note: All information put in Court documents becomes public record.  If you have information you wish to keep private please inform us of that when we call for your consultation.


What is the best phone number to reach you by during the day? Home Work Cell


Mailing address:


City   State   Zip

Date of birth

Would you like for us to set your account up to receive text-alerts as your case proceeds?

Section 2 - Other Party's Contact Information:


Home phone Work phone Cell phone

Mailing or severable address:

Street   Apt.

City   State   Zip

Date of birth

Section 3 - Reason for Contacting Discount Divorce & Bankruptcy

Tell us a little about what is going on and how we can help you?

Section 4-Contact

Discount Divorce will immediately begin work on your case as soon as your initial phone consultation is complete and your payment is received.


Discount Divorce will call you between the hours of 9AM and 4PM, Monday thru Friday.

What is the best time to reach you at during the hours listed above? Any time after

Section 5 -  Terms of Service

Terms of Service

I acknowledge that I have read the "Terms of Service and agree and understand them. Yes No

Applicant Name/E-Signature: I certify that all information contained herein is true and correct.

Date (mm/dd/yyyy):