Interview

The first step in eliminating your debt is to complete this free on-line interview. After analysis of your data, you will be contacted with some helpful advice and tips on how to resolve your specific credit situation. You can also download a copy of this form in Adobe Acrobat format to fill out and mail to our offices.

All information submitted will be kept strictly confidential and be used solely for purpose of this analysis. You can review our privacy policy for additional information on how we collect and use data.

Download as PDF

Please fill out this form accordingly.

Contact Form Demo

What is your first name?

And what is your last name?

What is Phone Number?

Marital Status

If yes, what is your spouse's full name?

If yes, what is your spouse's email address?

About You

Have you filed for bankruptcy before?

Are you employed?

Occupation

Your Employer

Subject

Length of Employment

What are your gross wages per pay period?

What is your take home (net) per pay period?

Do you have income from any other source(s)? If yes, state source and amount.

How Often Are You Paid

Do you rent or own?

If rent, how much monthly?

If own, what is value of residence?

Spouse's Employment (if applicable)

Is your spouse employed?

Occupation

Employer

Length of Employment

How Often is Your Spouse Paid?

Gross wages per pay period

Take home (net) per pay period

Do they have income from any other source(s)? If yes, state source and amount.

Questions about Mortgage (if applicable)

Name of Lender

Loan Balance

Monthly Payment

Are you current?

Yes

Do you own any other real estate?

Yes

If behind, how far?

Value of other real estate (if applicable)

Vehicles (if applicable)

Year, make and model of car

Value of car

Do you owe money on this car?

Yes

If yes, name of creditor

Total Amount Owed

Monthly Payment Amount

Number of Payments Remaining

Year, make and model of second care (if any)

Value of car

Additional Vehicles

Do you have an Additional Vehicles?

Yes

Year, make and model of car

Value of car

Bank Accounts

Account type

Name of Bank

Approximate Balance

Other Deposit accounts

Other Assets

Liabilities

Other than mortgages and lienholders on vehicles, do you have any other secured debt? (For example: furniture, jewelry, boats, RV's, business equipment, etc.) If so, describe collateral.

Name of creditor

Total Amount Owed

Value

Monthly Payment

Number of payments remaining

Do you owe any taxes?

Yes

If Yes, do you owe income taxes?

Yes

If Yes, do you owe the IRS or state, or both?

IRS

State

Both

If No, what other type of taxes do you owe?

Total amount owed

Do you owe any student loans?

Yes

Total amount owed

Do you owe any court fines (such as DUI's), back spousal support, welfare, or social security overpayment?

Yes

If yes, type of debt?

Total Amount Owned

List All Remaining Unsecured Creditors

Credit Cards

Name(s) of Creditor(s)

Total amount owed

Medical Bills

Name(s) of Creditor(s)

Total amount owed

Personal Loans

Name(s) of Creditor(s)

Total amount owed

Other unsecured liabilities:

Type of debt (utility bills, collection accounts, etc.)

Name(s) of Creditor(s)

Total amount owed

Judgments

Name of Judgment Creditor

Date Judgment Entered

Additional Information

Please provide any additional information not indicated above that you think is important, such as foreclosures, bank levies, wage garnishments, etc.

Additional Information