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Boston Bankruptcy Evaluation

Personal Information

Name:

Phone:

Email:

City:

State:

Zip:

Specify day/time for a return call:

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:

2st 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 Payment:

Are your payments up-to-date?
Yes
No

Vehicle 2

Year:

Make:

Model:

Value:

Balance:

Monthly Payment:

Are your payments up-to-date?
Yes
No

Income

You

How often do you get paid?
Every Week
Every 2 Weeks
Twice a Month
Monthly
Gross Pay:

Spouse

How often do you get paid?
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
Part-time Job
Social Security
Child Support
Pension
Unemployment
Rental Property
Worker's Comp
Monthly Amount:

20 Park Plaza, 4th Floor
Boston, Massachusetts 02116
phone: 800-975-5346

Member, National Association of Consumer Bankruptcy Attorneys

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