This is your first step down the path to financial freedom. If you are having difficulty paying your bills, fill out as much as you wish to disclose at this point. All information is held in complete confidence. A counselor will review your information and contact you by your chosen method (E-mail, fax, or phone).
YOUR CONTACT & SITUATION INFORMATION
*First /*Last: /
Address:
City/State/*Zip //
*Phone/ Fax: /
*E-mail:
Birthdate/SSN# /
Sex/Marital/Edu
SPOUSE  
First/Last: /
Birthdate/SSN# /
Sex/Marital/Edu
*How should we contact you?
How did you find us?
Reason for contacting us?
Other response if desired:
Are payments current or behind?
What is your goal?
Your Income: $
Your Employer:
Spouse Income: $
Spouse Employer:
 
MONTHLY EXPENSE INFORMATION
HOUSING
Mortgage Rent
Home/Renters Insurance Home Maintenance
Property Tax Vacation Lodging
Other Realty  
UTILITIES
Gas/Electric Telephone
Water/Sewer/Garbage Cell Phone/Pager
Cable TV/ Internet  
FOOD/BEVERAGE
Groceries Lunches/Dining Out
TRANSPORTATION
Car Payments Auto Insurance
Gas and Maintenance Recreational Vehicle
HEALTH CARE
Health Insurance Medical Expense
Life Insurance  
CASH CONTRIBUTIONS
Donation/Tithe  
PERSONAL SERVICES
Presents/Gifts Cleaning/Laundry
Hair/Personal Clothing
Other  
ENTERTAINMENT
Fees and Admissions Equipment
MISC.
Education Other Insurance
Child Support Child Care
Savings/Investments Other Debt

ACCOUNTS
Creditor Name Account Number Account Type Current Balance Payment
(Amount Due)

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