Client application
* Required fields
First name:
*
Last name:
*
First name (spouse):
Last name (spouse):
Email address:
*
Marital status
: *
Make a selection
Single
Married
Widowed
Separated
Divorced
Other
State you live in:
*
County:
Home phone:
*
Ages:
Number of dependents:
How did you find about us?
Make a selection
Bank/credit union
NFCC/800
Creditor
Current client
Friend/family member
Financial planner
Radio/tv/newspaper
Internet
EAP/Employer
Attorney
Social Services
Physician/health provider/therapist
Phone book
Credit unions
Other
How should we contact you?
*
Make a selection
Email
Phone
What's a good time?
Please let us know how we can help you:
*
Income
Monthly net pay (self):
*
Monthly net pay (spouse):
Have you ever filed bankruptcy?
*
Make a selection
No
Yes - Chapter 7
Yes - Chapter 13
If so when? (Year):
Other income: Child support, Rental, Retirement/Pension, P.T. Seasonal, UC:
Monthly: $
Comments:
Assets or equity
Checking account:
$
Savings account:
$
Savings bond/Stocks / mutual funds:
$
401(K)(B):
$
Retirement:
$
Other assets:
$
Home / Property
Home
Mobile home
Land
Rental
Value(s):
Balance(s) owed:
Housing:
Own
Rent
Mortgage/Rent per month:
$
Delinquent:
Yes
No
Number months delinquent:
Vehicles / Boats / Cycles / Campers
Year:
Make:
Monthly payment:
Balance owed:
Year:
Make:
Monthly payment:
Balance owed:
Monthly payments for unsecured debts
Creditor 1:
Balance:
Mo payment:
Interest rate:
Creditor 2:
Balance:
Mo payment:
Interest rate:
Creditor 3:
Balance:
Mo payment:
Interest rate:
Creditor 4:
Balance:
Mo payment:
Interest rate:
Creditor 5:
Balance:
Mo payment:
Interest rate:
Creditor 6:
Balance:
Mo payment:
Interest rate:
Creditor 7:
Balance:
Mo payment:
Interest rate:
Creditor 8:
Balance:
Mo payment:
Interest rate:
Creditor 9:
Balance:
Mo payment:
Interest rate:
Creditor 10:
Balance:
Mo payment:
Interest rate:
Monthly living expenses
Condo fees/Park rent:
H20 softener/Drinking:
Utilities:
Cell phone/Pager:
Water/Sewer/Garbage:
Renter's/Homeowner's insurance:
Home repair/Maintenance:
Cable TV/Dish:
Video rentals/CDs/Music/DVDs:
Online computer access:
Food/Groceries/Supplies:
Meals out:
Gas/Public transportation:
Auto insurance:
Auto repair/Maintenance:
Auto registration:
Parking:
Maintenance/Child support:
Day care/Babysitting:
Baby supplies:
School expenses/Tuition:
Child allowance:
Clothing:
Laundry & dry cleaning:
Personal care:
Occupational/proff expenses:
Medical/Disability ins./Copay:
Prescriptions/Medical care:
Life insurance:
Donations:
Bank fees:
Gifts:
Pet care:
Cigarettes:
Alcohol:
Entertainment:
Newspapers/Magazines/Books:
Bingo/Casino/Lottery:
Vacation/Trips:
Savings:
Other periodic expenses:
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