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Anadel Canale P.C.

Attorney At Law

[email protected]

___________________________________

Long Island Office (Main Office)

1805 5th Avenue

Bayshore, NY 11706

Valley Stream

962 Rockaway Ave

Valley Stream, NY 11581

516-588-7265

COLLECTIONS INTAKE FORM

Formulario de Admisión de Casos de Cobranza

CLIENT INFO:

Información del Cliente

Full Name (Nombre completo) *

Email (Correo electrónico) *

Phone (Teléfono) *

Date of birth (Fecha de nacimiento) *

Last 4 digits of SS# (Últimos cuatro dígitos del Seguro Social) *

Current Address (Dirección actual) *

State of Residence (Estado de residencia) *

CASE DETAILS:

Detalles del Caso

Have you been served with legal papers? (¿Ha recibido documentos legales?) (Yes/No) *

Yes

Name of creditor suing you (Nombre del acreedor que lo está demandando) *

Amount of debt (Monto de la deuda) *

Have you ever filed bankruptcy? (¿Ha declarado bancarrota anteriormente?) (Yes/No) *

Yes

How many creditors do you have? (¿Cuántos acreedores tiene?) *

How many accounts are past due? (¿Cuántas cuentas están vencidas?) *

Do you own a home? (¿Es propietario de una vivienda?) (Yes/No) *

Yes

Annual income range (Rango de ingresos anuales) *

QUESTION FIELD:

Campo de Pregunta

What question would you like Attorney Anadel Canale to answer? (¿Qué pregunta le gustaría que la Abogada Anadel Canale responda?) *

DIGITAL RETAINER AGREEMENT

Acuerdo de Representación Digital

By checking this box, I hereby retain Attorney Anadel Canale, Esq., located at: 1805 5th Avenue, Bay Shore, NY 11706 and 960 Rockaway Avenue, Valley Stream, NY 11581 to prepare and file an Answer on my behalf in connection with a collections lawsuit or creditor claim.

Al marcar esta casilla, por la presente contrato a la Abogada Anadel Canale, Esq., ubicada en 1805 Fifth Avenue, Bay Shore, Nueva York 11706 y 960 Rockaway Avenue, Valley Stream, Nueva York 11581, para que prepare y presente una contestación en mi nombre en relación con una demanda de cobranza o reclamación de acreedor.

I understand and agree that by checking this box, the $750 flat fee applies solely to the preparation and filing of the Answer. This does not include court appearances, settlement negotiations, or bankruptcy filings. Additional legal services require a separate agreement and fee. Bankruptcy representation, if needed, is separate from this fee.

Entiendo y acepto que al marcar esta casilla, la tarifa fija de $750 aplica únicamente a la preparación y presentación de la contestación. Esto no incluye comparecencias ante el tribunal, negociaciones de conciliación ni presentaciones de bancarrota. Los servicios legales adicionales requieren un acuerdo y tarifa separados. La representación en bancarrota, de ser necesaria, es independiente de esta tarifa.

Collect Payment ($750 Flat Fee) *

$ 750

Protect Your Rights Before It’s Too Late

Don’t let creditors control your future. Take the first step toward legal protection today.

✔ Fast | ✔ Confidential | ✔ Response in 48 Hours

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