Name: *

Phone: *

Email address: *

Address:

City:

State:

Zip:

Time lived in Massachusetts: *

Have you ever filed bankruptcy?

Yes No

If you have filed bankruptcy before, please answer the next 3 questions.

    What year?

    What city and state?

    What type?

Chapter 7 Chapter 13

Marital and household status:

If you are married, please answer the next 4 questions.

    Do you want to file a joint bankruptcy?

Yes No

    Your spouse's employment status:

    Your spouse's job title or description:

    Your spouse's monthly "take home" income:

$

If you have dependents, how many:

Have you run or been a partner in a business in the last 6 years?

Yes No

If so, please answer the next 4 questions.

    Is the business still running?

Yes No

    Do you sell:

Services
Goods
Both goods and services

    What type of entity?

Sole proprietorship
S-Corporation
C-Corporation
LLC (limited liability company)
Partnership
Other:

    Name of business:

Employment status:

Job title or description:

Approximate net income per month (income from all sources):

$

If paid hourly, your hourly wage:

$

If salaried, your annual salary:

$

Monthly expenses are:

Average monthly household necessary living expenses:

$

Do you own a house?

Yes No

If you own a house, please answer the next 6 questions.

    Market value:

$

    Amount of first mortgage:

$

    Amount of second mortgage:

$

    Other home equity loan:

$

    Are you:

Current on house payments
Behind on house payments

    Do you want to:

Keep the house
Surrender the house

How many vehicles do you own?

If you own vehicles, please enter information for up to three vehicles:

1st Vehicle

    Year / model:

    Is the vehicle:

Paid off Still paying

    Do you want to:

Keep the vehicle
Surrender the vehicle

2nd Vehicle

    Year / model:

    Is the vehicle:

Paid off Still paying

    Do you want to:

Keep the vehicle
Surrender the vehicle

3rd Vehicle

   Year / model:

    Is the vehicle:

Paid off Still paying

    Do you want to:

Keep the vehicle
Surrender the vehicle

List any other secured debts besides a house or car (for example: financed furniture, computer or electronics, etc.)

List any other valuable asset(s) you own that you believe would be worth $1,000 or more if you sold them at a garage sale:

Do you have any of the following types of debt? If so, please fill in the amount by each.

Add up the total amount of debt from the items you listed above:

$

List any credit charges of $2,000 or more made on any individual credit card, personal loan, or with any other creditor within the last 6 months. Include name of creditor and total amount charged.

List any cumulative payments of $4,000 or more made to any individual creditor within the last 6 months.

List any cumulative payments of $1,000 or more made to any close family member within the last year.

Which have happened to you within a year?

lawsuit
judgment
garnished
repossession

We will attempt to respond within 48 hours.

If you would like assistance with this form, please contact our office at (978) 740-2805 or pkaplaw@aol.com