Bankruptcy and Debt

If your problem is not a insert the correct one problem, use a different application.

MJP will need to speak with you on the telephone or in person.  MJP will need to verify your eligibility for services and may need to gather more information about your situation.

Your E-mail address
Only provide an email address if you are the only person who has access to it
First name *
Middle name
Last name *
Maiden Name
Alias or Other Names You Go By
Date of Birth *
Street Address *
Address line 2
City *
Zip Code *
Home phone #
Work phone #
Cell phone #
The best phone number for us to call
      

Is it safe for us to call at this number? *
    

Best time to reach you, Monday through Friday between 9 a.m. and 4 p.m.
Is it safe for us to leave a message at this number? *
    

Please describe any special instructions or information we need to know about how to contact you or the person for whom you are applying for services

If you are submitting this application for another person, please tell us your name and your relationship to the applicant (family member, service provider, etc.)

Provide the name of the person with whom you have the dispute

The number of adults and the number of children under age 18 who live with you, including yourself (ex. 3 adults 2 children) *
Is anyone in this household currently a victim of domestic violence?
    

Person Receiving Income *
Income source *
Gross income amount for this source *
How often is this amount received *
        

Person receiving income
Income Source
Gross income amount for this source
How often is this amount received
        

Other income information

Include who receives, from where, how much and how often
Please select ASSETs owned by all persons in the household *













Value of assets *

If you are having a problem paying your DEBTS, please check or answer all that apply.








Have you ever filed for bankruptcy before?
    

If yes, when?
How did you hear about us?
Have you or any member of your household served in the military?
    

We provide mostly information, referrals, advice and some brief legal help. We do not usually provide representation. In reply to your intake we may: give you information and materials only, or offer some legal advise or brief assistance.
To refer your case for further help or possible representation we need your permission to share information about your case with: Community Legal Aid, or a private volunteer attorney, or other legal Services program that covers your area.
By submitting this application, you agree to these terms.
Enter dollars per hour
How many hours do you work per week?
Enter this number in the monthly column.


Calculator figures "Dollar Per Hour" x "Hours Per Week" x 4.33 weeks in a month.

Income includes, but is not limited to: money, wages, salaries before any deductions, income for self-employment after deductions for business or farm expenses; regular payments from governmental programs for low income persons or persons with disabilities; social security payments; unemployment and worker's compensation payments; strike benefits from union funds; veterans benefits; training stipends, alimony; child support payments; military family allotments; public or private employee pensions; regular insurance or annuity payments; income from dividends, interest, rent, royalties or from estate trusts; and other regular or recurring sources of financial support that are currently and actually available.

Do not include value of food or rent received by you in lieu of wages; money withdrawn from the bank; tax refunds; gifts; compensation and/or one-time insurance payments for injuries sustained; non-cash benefits; and up to $2000 per year of funds received by individual Native Americans that is derived from Indian trust income or other distribution exempt by statue.