August 19, 2008
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1-800-557-1985
Debt Care Specialist Available NOW!!
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A
CCC
Certified Credit Counselor will contact you within 2 hours (8am-6pm EST Mon.-Fri.) All information is handled
confidentially
.
General Information
E-mail address
*(required field)
Your Full Name
*(required field)
Spouse Name
StreetAddress
City
State
Zip
HomePhone
*(required field)
Work or Cell Phone
Fax
How did you hear about us
Best Time of Day to call
Your Income
Monthly Take Home Pay
Spouse Take Home Pay
Other Income
Clients Employer
Expenses
Tithes Charity
Rent Mortgage
Lot Rent
Property Tax
Home Owners Renters
Electricity
Water/Sewer
Gas
Phone
Cable TV /Internet
Food
CarPayment 1
Gas Oil
Car Payment 2
Auto Insurance
Child Care Tuition
Other
Client Debt Information
Please fill in the Debt Summary using information from your most Current Statements. Our counselors work with all credit cards, department stores, gas cards, and other unsecured debts.
Comments
-Please let us know about any urgent issues
(such as anticipated changes in your income or expenses.
Creditor Name
Debt Type
Current Balance
Interest Rate
(APR)
Amount Delinquent
Minimum Payment
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