LAW OFFICES OF MARK H. AVERY

158 Center Street (RT. 14)

P.O. Box 862

PEMBROKE, MASSACHUSETTS 02359

Telephone: (781) 294-7855

E-mail:

Web:

BANKRUPTCY QUESTIONNAIRE

(For bankruptcies filed after October 17th, 2005)

Please take the time to complete this questionnaire. The information requested is necessary to complete a Bankruptcy petition for Chapter 7 or 13. If a question is not applicable, answer none. Please answer each question honestly and in complete detail. Keep in mind that under the U.S. Bankruptcy Law:

  • All the information disclosed must be complete, accurate and truthful.
  • All of your assets, and liabilities must be completely and accurately disclosed, including the disclosure of each item’s replacement value.
  • Your Monthly income must be accurately disclosed, including your past six months income necessary to complete the “Means Test” evaluation.
  • The information that you provide will be used to prepare your bankruptcy petition and to present at the Trustees Meeting in your case. All such information may be audited by the U.S. Justice Department.
  • The failure to provide the requested information may result in a dismissal of your bankruptcy case and penalties against you, including incarceration (Don’t lie about your assets, liabilities, income or expenses!)

If you are filing a joint bankruptcy or if you live with your spouse and are filing chapter 13 answer the questions for both yourself and your spouse. Please carefully disclose all information required. If you need assistance or do not understand any portion of this questionnaire, please call me, or we can sit down and review it together. If there is not enough room on the questionnaire to answer the question, attach separate sheets. After you have completed the questionnaire, please read it, review it and sign and date it and return it to my office.

Attached to this Questionnaire is the Official Two Page Bankruptcy Disclosure (under section 342(b). Please read it, review it, and sign and date it. Thank you.

For Your information:

The Filing Fee for Chapter 7 is $306.00

The Filing Fee for Chapter 13 is 281.00

PART ONE - BASIC INFORMATION

YOUYOUR SPOUSE

1.a. Name:a.

b. Other names (i.e. maiden, trade name, etc.): b.

c. Social Security Number c.

d. Address

e. Mailing address

f. Telephone Number day :

evening :

g. E-Mail

2. Are you filing bankruptcy yourself or with your spouse?

3. Have you, your spouse, or a business partner filed bankruptcy within the past 8 years? If so, please give the name, location and docket number of the case and the date it was filed.

PART TWO - ASSETS & LIABILITIES

A.Real Property

1. List the addresses of all real property that you own. List the name that the property is owned in (i.e. you, you and your wife, you and someone else, etc.)

2. List the Fair market Value and include a copy of your tax bill and an appraisal for each piece of real property (homes, land, condominiums) with this questionnaire. You may need to have a real estate appraisal done of the property.

3. List the Mortgages on each property together with the complete address of the Mortgage Holder and the principal balance due on each mortgage.

Property Address Mortgage Holder AddressPrincipal Balance Due

4. Do you have a HOMESTEAD on your Property. Provide a Copy of Homestead. When was it filed?

5. Have you OWNED any real property within the past ten years? What happened to it? (Was it sold, given away, placed into a trust, lost in a divorce, etc. Also list the ADDRESS of that property)

6. Do you RENT to anyone? If so, give an itemized list of rents received and expenses related to rental property.

B. Personal Property:

  1. How much cash on hand do you have?

2. List bank accounts, together with account balances.

Bank/Financial Institution Account No./Type Account Balance

3. Do you have security deposits with anyone? If so state the name of the person with the deposit and the amount. (i.e. rental deposit)

4. Give an estimate of the fair market value of your household belongings, including audio, video and computer equipment (including replacement costs) You may list items on the back of this page.

5. Do you have any collections (i.e. coin, stamp, antique, etc.)? If you do give the type and value of each collection.

Give estimates of the value of the following (questions 6-33):

6. your wardrobe

7. furs & jewelry

  1. firearms, sports equipment, photo & hobby equipment
  1. List whole life insurance policies that you own.(the type you can cash out without dying)

Company Name Surrender or Refund Value

  1. List any annuities that you own with the name and value of each.

11. List all pensions that you have (i.e. IRA, Keogh, etc.)

Pension Name Value ERISA qualified?

(if you do not know if your pension is ERISA qualified ask your pension administrator)

12. List stocks you own with the value of each.

13. List interests you have in partnerships or joint ventures

14. List Bonds that you own with the value of each

15. Does anyone owe you money? (accounts receivable) List each.

16. Are you entitled to money or property from a divorce? Describe

17. Are you entitled to a tax refund? How much?

18. Do you have any future interests, life estates etc.

(if you do not know what one is, you probably do not have one)

19. Are you entitled to an inheritance, insurance proceeds, or other benefit due to a death? Describe

20. Do you have any lawsuits or the possibility of a lawsuit against someone? Describe

21. Do you own any patents or copyrights? Describe

22. Do you have any special license (i.e. liquor, food)? Describe

23.List all vehicles you own:

Year Make Model Fair Market Value

24. List any boats

25. List any aircraft

26. Do you have office equipment? List each piece with value

27. Do you have business machinery? List each piece with value

28. Do you have inventory? Describe with value

29. Do you own animals other than pets? Describe and include value

30. Do you have crops?

31. Farming equipment?

32. Farm supplies?

33. Do you have any interest in an Educational IRA

34. Do you have any interest in customer lists or goodwill ?

35. Any other property not listed above?

D. Secured Creditors (CAR LOANS HOME EQUITY LOANS etc.)

List the names and addresses of anyone who is financing any of your property (i.e. car loan, second mortgage etc.)(include copy of statement if available)

Creditor Name & Address Item Financed Amount Owed Value of Property

E. Priority Debts (TAXES, Court Ordered Payments like Child Support)

1. Do you owe anyone wages or the return of a security deposit? If yes, give details.

2. List any amounts that you owe for taxes, interest or penalties to the I.R.S., state taxes, real estate taxes, or excise taxes. State the year the amount due is from (i.e. $3,000 1994 income taxes $2,000 penalties and interest IRS)(include copies of any notices)

3. Do you owe any money for Alimony? If so, how much?

4. Do you owe any money for Child support obiligations? If so, how much?

5. Do you owe any money as a result of a Divorce or Paternity action? Please describe the amount and what it is for (attorneys fees, medical bills, college expenses etc.)

F. Unsecured Debts.

Make a list or give a copy of your bills showing the addresses and balances for all of your credit cards, medical bills, loans and other debts. State whose name the debt is in if you are filing a joint bankruptcy.

Do you have any JUDGMENTS against you? If so, please list the name of the creditor, or person who has a judgment against you.

Do you have any judgment against you for damage caused drunk driving?

G. Leases

1. If you rent your home or office, give the name and address of your landlord, together with the address of the rented property and the amount of the rent.

2. If you lease a car, other vehicle or any other property, state the name and address of the company you lease from, a description of the leased vehicle and the lease amount.

H. CoDebtors Of any of the debts listed, does anyone else owe the money with you (i.e. a cosigner, guarantor, etc.) State the name and address of the codebtor and the name and address of the creditor.

I. Income

  1. List your marital status (single, married, divorced) and the ages of your children or other dependents. (If you are filing a joint chapter 7 petition or chapter 13 (with or without your spouse) you must include information for your spouse as well.

2. State your occupation, and the name and address of your employer, and how long you have worked there.

3. State your monthly gross income (before taxes), and your monthly take home pay (after all deductions). State how much is regular pay and how much is overtime. Are you paid WEEKLY or Every Other Week?

4. List your monthly deductions and what the deductions are for. (i.e. taxes, medical insurance, union dues, 401K plan, etc.)

TAXES INSURANCE PENSION OTHER (Describe)

5. List any other income that you have:

. You Spouse

  1. rental income:$$
  2. child support,:$$
  3. alimony:$$
  4. interest: $$
  5. pension: $$
  6. social security: $$
  7. AFDC:$$
  8. Disability:$$
  9. Contributions

from other family

members$$

j. Trust Fund$$

k. Other$$

______

For questions 2 - 5, if you need to figure the monthly amount; for a weekly item multiply by 4.3, for a biweekly item multiply by 2.15 and for yearly items divide by 12. Consult your paystub, bills or other documents for the figures. Please enclose copies of your paystubs for an average weeks work from each job. (i.e. if you work 40 hours, enclose a copy of a 40 hour work week paystub)

PROVIDE PROOF OF INCOME FOR THE PAST SIX MONTHS (can be bank statements, pay stubs, quarterly tax statements etc.)(required under 2005 Bankruptcy Reform Act)

J. Expenses

List your monthly expenses:

1. Rent or home mortgage payment

a. Are real estate taxes included in the mortgage?

b. If not, how much are taxes?

c. Is property insurance included in the mortgage?

d. If not, how much is property insurance?

2. Utilities a. electric & heating fuelb. water & sewer

c. telephoned. cable t.v.

e. any other utility:

3. Home maintenance4. Food

5. Clothing6. Laundry & dry cleaning

7. Medical and dental expenses8. Transportation (gas, etc.,not car payments)

9. Recreation & entertainment10. Charitable Contributions

11. Insurancea. homeowners or rentersb. life

c. autod. other

12. Taxes (not deducted from wages or included in your mortgage payment)

13. Installment payments

a. auto

b. second auto

c. list any other

14. Alimony or child support

15. Any other regular expenses

Total:

DEBT COUNSELING (If you don’t know where to go for debt counseling, we have the names of several agencies that provide pre and post debt counseling as required under the new laws)

What agency have you gone to for debt counseling?

When did you complete your debt counseling?

Please provide a CERTIFICATE from the debt counsel agency showing that you have completed the 2005 Bankruptcy Reform Act required debt counseling.

If you have NOT completed Debt counseling, please do so as soon as possible. I will give you an information sheet

PART III - DECISIONS TO KEEP OR RETURN PROPERTY

A. 1. For property that you make monthly payments on, list what property you wish to keep:

2. Do you wish to continue to make payments, or can you pay for the full value of the item. (i.e. if your car is worth $2,000 and you owe $3,000 you may continue making monthly car payments or pay the fair market value of $2,000)

B.1. For property that you make monthly payments on, list what property you wish to give back:

2. When can the creditor pick the item up?

PART IV YOUR FINANCIAL AFFAIRS

1. What was your income from your jobs) for each of the past two years? What has your income been so far this year?

2. Have you earned income from a source other than your job? List your income for the past two years from other sources and state where it came from.

3. a. Have you paid any creditor over $600 within the past three months? If you have give the name and address of the creditor, the amount paid, and the date(s)

b. Have you paid any relative or business associate money owed to them within the past year? If you have give their name and address, the amount paid, and the date(s)

4. a. Have you been in any lawsuits within the past year? If you have, state the case name and number, the court that it is in, and a brief summary of the case.

b. Has any of your property been attached, garnished or seized within the last year?

5. Has any of your property been repossessed, foreclosed on or returned?

6. Have you assigned any of your property within the last 6 months or placed it with a receiver.

If any of questions 4b-6 is yes, state the name and address of the person with the property, what the property was and its value.

7. Have you made any gifts or contributions of over $200 in value?

8. Have you had any losses from fire, theft, gambling or other casualty. If you have what was lost, what was the value, what was the date of the loss and are you expecting insurance proceeds?

9. Have you paid anyone else for debt counseling or bankruptcy within the past year?

If you have give the persons name and address, the amount paid and the date.

10. Have you transferred any other property to anyone within the last year. Give details

.

11 Have you closed any bank accounts within the last year? If you have list the account, the final balance and the date you closed the account.

12. Do you have any safety deposit boxes or did you within the last year? If you do, where is it, and what is in it and if you did, where was it, what was in it, and when was it removed?

13. Has any bank taken money from any of your accounts within the last three months for money that you owed (a setoff)

14. Are you holding property for anyone else? If you are, who owns it, what is it and how much is it worth?

15. List all your addresses within the last two years, with the dates you lived there. (You do not need to include your present address)

16. Were you ever married or lived with a person in a community property state within the past ten years? (Alaska, Arizona, California, Idaho, Lousiana, Nevada, New Mexico, Puerto Rico, Texas, Washington or Wisconsin)

17. If you are in business with a partner, corporation, or self employed be sure to request and complete the Supplemental Questionnaire.

Print your name(s) on the line and sign and date below.

I / We ______, have read this questionnaire and answered all questions truthfully and accurately, and I understand that my attorney will use this information to prepare a Bankruptcy Petition and file it on my / our behalf. I further understand that if untruthful or inaccurate information is in my bankruptcy, that my bankruptcy may be dismissed and if the court finds that I have deliberately filed my bankruptcy with fraudulent information that penalties range from civil fines to incarceration.

Signed under the pains and penalties of perjury.

______

Debtor SignatureDate

______

Co Debtor SignatureDate

B 201 (10/05)

UNITED STATES BANKRUPTCY COURT

NOTICE TO INDIVIDUAL CONSUMER DEBTOR UNDER § 342(b)
OF THE BANKRUPTCY CODE

In accordance with § 342(b) of the Bankruptcy Code, this notice: (1) Describes briefly the services available from credit counseling services; (2) Describes briefly the purposes, benefits and costs of the four types of bankruptcy proceedings you may commence; and (3) Informs you about bankruptcy crimes and notifies you that the Attorney General may examine all information you supply in connection with a bankruptcy case. You are cautioned that bankruptcy law is complicated and not easily described. Thus, you may wish to seek the advice of an attorney to learn of your rights and responsibilities should you decide to file a petition. Court employees cannot give you legal advice.

  1. Services Available from Credit Counseling Agencies

With limited exceptions, § 109(h) of the Bankruptcy Code requires that all individual debtors who file for bankruptcy relief on or after October 17, 2005, receive a briefing that outlines the available opportunities for credit counseling and provides assistance in performing a budget analysis. The briefing must be given within 180 daysbeforethe bankruptcy filing. The briefing may be provided individually or in a group (including briefings conducted by telephone or on the Internet) and must be provided by a nonprofit budget and credit counseling agency approved by the United States trustee or bankruptcy administrator. The clerk of the bankruptcy court has a list that you may consult of the approved budget and credit counseling agencies.