* First Name

* Last Name

* Email

* Address

* Apt/Floor

* City

* State

* Zip Code

* Subject

* Telephone

* Please specify day and time to be contacted

What type of bills do you have? Please check all that apply: Credit Cards
Medical Bills
Judgements
Student Loans
Tax Debts
Government Fines (parking tickets, moving violations, suspensions)
Personal Loans

Total Number of Bills

Total Amount Under $5,000
$10,000-$15,000
$15,000-$20,000
$20,000-$30,000
$40,000-$50,000
Over $50,000

Additional Information

Approx. Value of Home

Approx. Balance on Mortgage

Monthly Mortgage Payment

Are you up to date with your mortgage payments? Yes
No

Are there any other mortgages on this property? Yes
No

Vehicle 1

Year

Make

Model

Approx. Value

Approx. Balance

Monthly Payment

Are your payments up to date? Yes
No

Vehicle 2 (Optional)

Year

Make

Model

Approx. Value

Approx. Balance

Monthly Payment

Are your payments up to date? Yes
No

Please list any other significant property

* How often do you get paid? Every week
Every 2 weeks
Twice a month
Monthly

* Net Pay

How often do you get paid? Every week
Every 2 weeks
Twice a month
Monthly

Net Pay

What other types of income do you have? Please check all that apply: Disability
Social Security
Pension
Rental Property
Part-time job
Child Support
Unemployment
Worker's Compensation