Bankruptcy Form- page 1 of 3

Name:

Address:

City:

State:

Phone:

Email:

Have you lived in New Hampshire for the past One Hundred Eighty (180) days?

Yes:

No:

If no, where have you lived?

Have you ever filed Bankruptcy in the past?

Yes:

No:

Spouse's Full Name:

Has your spouse filed Bankruptcy in the past?

Yes:

No:

Number of dependents:

Ages:

Do you own a home?

Yes:

No:

Do you own other real estate, including Timeshares?

Yes:

No:

Do you own or lease a vehicle?

Yes:

No: