A non profit community service agency helping people with finances
Web Payment
$2 Transaction Fee 
 
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Debt Eliminationv
Bankruptcyv
About Usv
Client Login
 
A. Tell us about yourself

Last Name:* First Name:* M.I.:
Maiden:
Date of Birth:*  
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Sex:
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Ethnic Background:
Marital Status:
If married, name of spouse:
Last Name:
First Name:
M.I.:
Maiden: 
Date of Birth:  
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Age:
Number of children living in your home:
Ages:
Are you:
Have you ever received credit counseling before?
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Filed bankruptcy? Year?
Approximately, how much federal tax refund, if any, did you receive last year?
B. How can we contact you?
Mailing Address:*
City:* State:* Zip:* EMail:*
Home Phone:
Your Work Phone:
Cell Phone:
Spouse work phone:
C. Co-Applicants
(Any person other than you or a spouse, whose name appears on any creditor statement)
Name Relationship
D. Monthly Household Income
(All sources of income used for living expenses)
Source Pay Periods Per Month Take Home Per Period Monthly Sub-Totals
Your Income:
Spouse:
Other:
Other:
Total Monthly Net Take Home Income:
Estimated Annual Gross Income:
E. Living Expenses
Living Expenses Monthly Estimates
Rent
Mortgage
Second Mortgage
Car 1
Car 2
Natural Gas, Propane
Water
Electricity
Telephone
Cell Phone, Pager
Cable TV, Satellite, Internet
Groceries, Toiletries, Cleaning Supplies
Lunch, Vending at Work
School Lunches
Dinners Out
Child Care
Child Support
Medical, Prescription Drugs
Gasoline
Car Maintenance & Repair
Car Insurance
Health, Life Insurance
Homeowner's, Renter's Insurance*
Real Estate Taxes*
Personal Property Taxes
Tithe, Offerings, Charity
Dry Cleaning, Laundromat
Tobacco, Alcohol
Entertainment, Vacations
Clothing
Tuition, Books, Supplies
Barber, Beauty Shop
Subscriptions
Other: Pets, Club Dues, Misc.
* Do not list if included in house payment
F. Creditors
Name of Creditor Balance Current Payment Intertest Rate
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G. Counseling Services Agreement
H. Statement of Privacy and Confidentiality
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