LAW OFFICES OF MARK H. AVERY
158 Center Street (RT. 14)
P.O. Box 862
PEMBROKE, MASSACHUSETTS 02359
Telephone: (781) 294-7855
(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.
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
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
Page 1 of Bankruptcy Questionnaire
PART ONE - BASIC INFORMATION
YOU YOUR SPOUSE
1. a. Name: a.
b. Other names (i.e. maiden, trade name, etc.): b.
c. Social Security Number c.
e. Mailing address
f. Telephone Number day :
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 Address Principal 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)
Page 2 of Bankruptcy Questionnaire
6. Do you RENT to anyone? If so, give an itemized list of rents received and expenses related to
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
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
8. firearms, sports equipment, photo & hobby equipment
9. List whole life insurance policies that you own.(the type you can cash out without dying)
Company Name Surrender or Refund Value
10. 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
Page 3 of Bankruptcy Questionnaire
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?
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?
Page 4 of Bankruptcy Questionnaire
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
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?
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
Page 5 of Bankruptcy Questionnaire
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
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
a. rental income: $ $
b. child support,: $ $
c. alimony: $ $
d. interest: $ $
e. pension: $ $
f. social security: $ $
g. AFDC: $ $
h. Disability: $ $
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)
Page 6 of Bankruptcy Questionnaire
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 fuel b. water & sewer
c. telephone d. cable t.v.
e. any other utility:
3. Home maintenance 4. Food
5. Clothing 6. Laundry & dry cleaning
7. Medical and dental expenses 8. Transportation (gas, etc.,not car payments)
9. Recreation & entertainment 10. Charitable Contributions
11. Insurance a. homeowners or renters b. life
c. auto d. other
12. Taxes (not deducted from wages or included in your mortgage payment)
13. Installment payments
b. second auto
c. list any other
14. Alimony or child support
15. Any other regular expenses
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
Page 7 of Bankruptcy Questionnaire
PART III - DECISIONS TO KEEP OR RETURN PROPERTY
A. 1. For property that you make monthly payments on, list what property you wish to
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
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?
Page 8 of Bankruptcy Questionnaire
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 Signature Date
Co Debtor Signature Date
Page 9 of Bankruptcy Questionnaire
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 pur poses, 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 o pportunities for credit
counseling and provides assistance in performing a budget analysis. The briefing must be given within 180 days before the
bankruptcy filing. The briefing may be provided individually or in a group (including briefings conducted by t elephone 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
In addition, after filing a bankruptcy case, an individual debtor generally must complete a financial
management instructional course before he or she can receive a discharge. The clerk also has a list of approved
financial management instructional courses.
2. The Four Chapters of the Bankruptcy Code Available to Individual Consumer Debtors
Chapter 7: Liquidation ($220 filing fee, $39 administrative fee, $15 trustee surcharge: Total fee $274)
1. Chapter 7 is designed for debtors in financial difficulty who do not have the ability to pay their
existing debts. Debtors whose debts are primarily consumer debts are subject to a "means test" designed to
determine whether the case should be permitted to proceed under chapter 7. If your income is greater than the
median income for your state of residence and family size, in some cases, creditors have the right to file a motion
requesting that the court dismiss your case under § 707(b) of the Code. It is up to the court to decide whether the
case should be dismissed.
2. Under chapter 7, you may claim certain of your property as exempt under governing law. A trustee
may have the right to take possession of and sell the remaining property that is not exempt and use the sale proceeds
to pay your creditors.
3. The purpose of filing a chapter 7 case is to obtain a discharge of your existing debts. If, however, you
are found to have committed certain kinds of improper conduct described in the Bankruptcy Code, the court may deny
your discharge and, if it does, the purpose for which you filed the bankruptcy petition will be defeated.
4. Even if you receive a general discharge, some particular debts are not discharged under the law.
Therefore, you may still be responsible for most taxes and student loans; deb ts incurred to pay nondischargeable
taxes; domestic support and property settlement obligations; most fines, penalties, forfeitures, and criminal restitution
obligations; certain debts which are not properly listed in your bankruptcy papers; and debts for death or personal
injury caused by operating a motor vehicle, vessel, or aircraft while intoxicated from alcohol or drugs. Also, if a
creditor can prove that a debt arose from fraud, breach of fiduciary duty, or theft, or from a willful and malicious
injury, the bankruptcy court may determine that the debt is not discharged.
Chapter 13: Repayment of All or Part of the Debts of an Individual with Regular Income ($150 filing fee, $39
administrative fee: Total fee $189)
1. Chapter 13 is designed for individuals with regular income who would like to pay all or part of
their debts in installments over a period of time. You are only eligible for chapter 13 if your debts do not exceed certain
dollar amounts set forth in the Bankruptcy Code.
Page 10 of Bankruptcy Questionnaire
B 201 Page 2
2. Under chapter 13, you must file with the court a plan to repay your creditors all or part of the money
that you owe them, using your future earnings. The period allowed by the court to repay your debts may be three
years or five years, depending upon your income and other factors. The court must approve your plan before it can
3. After completing the payments under your plan, your debts are generally discharged except for
domestic support obligations; most student loans; certain taxes; most criminal fines and restitution obligations; certain
debts which are not properly listed in your bankruptcy papers; certain debts for acts that caused death or personal
injury; and certain long term secured obligations.
Chapter 11: Reorganization ($1000 filing fee, $39 administrative fee: Total fee $1039)
Chapter 11 is designed for the reorganization of a business but is also available to consumer debtors. Its provisions
are quite complicated, and any decision by an individual to file a chapter 11 petition should be revi ewed with an attorney.
Chapter 12: Family Farmer or Fisherman ($200 filing fee, $39 administrative fee: Total fee $239)
Chapter 12 is designed to permit family farmers and fishermen to repay their debts over a period of time from
future earnings and is similar to chapter 13. The eligibility requirements are restrictive, limiting its use to those whose income
arises primarily from a family-owned farm or commercial fishing operation.
3. Bankruptcy Crimes and Availability of Bankruptcy Papers to Law Enforceme nt Officials
A person who knowingly and fraudulently conceals assets or makes a false oath or statement under penalty of
perjury, either orally or in writing, in connection with a bankruptcy case is subject to a fine, imprisonment, or both. All
information supplied by a debtor in connection with a bankruptcy case is subject to examination by the Attorney General acting
through the Office of the United States Trustee, the Office of the United States Attorney, and other components and employees
of the Department of Justice.
WARNING: Section 521(a)(1) of the Bankruptcy Code requires that you promptly file detailed information regarding your
creditors, assets, liabilities, income, expenses and general financial condition. Your bankruptcy case may be dismissed if this
information is not filed with the court within the time deadlines set by the Bankruptcy Code, the Bankruptcy Rules, and the local
rules of the court.
Certificate of the Attorney
I, Mark H. Avery, Esq, consel for the debtor(s), hereby certify that I delivered to the debtor(s) this notice required by Section
342 (b) of the Bankruptcy Code
Mark H. Avery, Esq. Date
Certificate of the Debtor(s)
I / We hereby affirm that I /we have received and read this notice.
Print name (Debtor) Signature (Debtor) Date
Print name (Co-Debtor) Signature (Co-debtor) Date
Page 11 of Bankruptcy Questionnaire