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MASSACHUSETTS BANKRUPTCY EVALUATION

PRESONAL INFORMATION
First Name:
Last Name:
E-mail:
Address:
City:
State:
Zip Code:
Phone:
Return Call Day:
Return Call Time:

BILLS
What type of bills do you have? Check all that apply:
Credit Cards
Medical Bills
Tax Debts
Student Loans
Total amount of Bills:
Under $5,000
$5,000 - $15,000
$15,000 - $20,000
$20,000 - $30,000
$30,000 - $50,000
$50,000 - $75,000
Over $75,000
PROPERTY
Approx. home value:
1st Mortgage Balance:
2nd Mortgage Balance:
Are you up to date on your mortgage payments?
Yes
No
Are there any other mortgages on this property?
Yes
No
VEHICLES
Vehicle 1:
Year:
Make:
Model:
Value:
Balance:
Monthly Payments:

Are your payments up-to-date?
Yes
No
Vehicle 2:
Year:
Make:
Model:
Value:
Balance:
Monthly Payments:

Are your payments up-to-date?
Yes
No
INCOME
How often do you get paid:
Every Week
Every 2 Weeks
Twice a Month
Monthly
Gross Pay:

How often does your spouse get paid(if applicable):
Every Week
Every 2 Weeks
Twice a Month
Monthly
Gross Pay:

OTHER INCOME
What other types of income do you have? Check all that apply:
Disability
Social Security
Pension
Rental Property
Part-time job
Child Support
Unemployment
Worker's Comp
Monthly Amount: