Speak to a Certified Credit Counselor by calling (800) 729-0551.


An Independent Non-Profit Tax Exempt Consumer Credit Counseling Service

Do not wait any longer, help is moments away. Fill out the form below being as specific and complete as possible. A certified counselor will contact you right away. Get back on the road to a debt free life.

Try to be as complete as possible to allow us a complete review of your situation. Entering multiple contact methods will allow us the greatest ability to contact you for your free analysis.


Personal Information
Client Name
Spouse Name
Home Address
City, State Zip  
Home Phone
Cellular Phone
Email Address
How would you like us to respond
Select all that apply
Home Phone Number
Cellular Phone Number
eMail
What is the best time to reach you
Services Interested in

Select all that apply
Budgeting and Spending
Credit Card Problems
Credit Reports
Debt Management Program DMP
Financial Education
Foreclosure
Payday Loan Help
Credit Status questions

Select all that apply
I am behind (past due) on my credit card account(s)
I am making only the minimum payment due on the account(s)
I have opened new account(s) within the past year
I really just need interest rate relief, no payment reduction
I have made recent purchases on the account(s)
I am behind (past due) on my secured debt and/or utilities
I have done recent balance transfers
I am currently on a hardship plan with at least one my creditors right now
I am currently enrolled in another agency now or have been in the past?
Income Information
Income Source Monthly Amount
Client Income
Spouse Income
Retirement Income
Social Security Income
Other Income
Expense Information
Item Monthly Amount
Rental Expense Do not include your mortgage payment
Telephone Expenses Home, Cellular, Pager
Auto Expenses Gas, Repairs, Registration (not your payment)
Insurance Expenses Home, Auto, Life, Medical
Childcare Expenses
Household Expenses
Utility Expenses Electric, Heating, Water, Gas, Cable, Internet
Food Expenses Groceries, Dining Out, Lunches
Medical Expenses Doctor Visits, Medicines
Education Expenses
Personal Expenses
Other Expenses
Secured Debts
Monthly Secured Debt Payments Mortgage, Auto, Student Loans Monthly Payments
Secured Debt Balances Mortgage, Auto, Student Loans Balances
Unsecured Debts
Monthly Credit Card Payments
Credit Card Balances
   


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Page was last modified: March 01 2013.