Fill out the pre-qualification

worksheet below and

click the submit button  

(This is just preliminary information to qualify you for a debt settlement program. It does not obligate you in any way)

Or  you may click on the form to download and print out

and then fax back to us:

 

Request for Program Work Sheet in

.doc Word  format

Request for Program Work Sheet in

 .pdf Adobe Reader format
Pre-Qualification Worksheet:
Name:
E mail:
Phone:

List the unsecured creditors with debt amounts of $500 and above

that you would like to enroll:   

1.Creditor Name Amount Owed 
2.Creditor Name Amount Owed 
3.Creditor Name Amount Owed 
4.Creditor Name Amount Owed 
5.Creditor Name Amount Owed 
6.Creditor Name Amount Owed 
7.Creditor Name Amount Owed 
8.Creditor Name Amount Owed 
9.Creditor Name Amount Owed 
10.Creditor Name Amount Owed 
11.Creditor Name Amount Owed 
12.Creditor Name Amount Owed 

(If you have more than twelve creditors complete this form and click submit and then hit refresh and enter the additional creditors on a second form just including your name above)

Monthly Net Income/Expense Overview:

APPLICANT - Monthly NET Income (less taxes and deductions)
SPOUSE - Monthly NET Income (less taxes and deductions)
OTHER -  (business, family, etc.)

Total Monthly NET Income:

NECESSARY MONTHLY EXPENSES:

(do not include credit card payments)

  
HOUSING: monthly rent or mortgage, property taxes (if not included in mortgage), insurance, parking, necessary maintenance and repair, homeowner dues, condominium fees, utilities (gas, electricity, water, fuel oil, coal, bottled gas, trash and garbage collection, wood and other fuels, septic cleaning, telephone, cell phone, internet, cable)
FOOD, CLOTHING, MISC: food, clothing and clothing services, supplies, personal care products
TRANSPORTATION: Enter your average monthly transportation expenses including lease or purchase payments, insurance, registration fees, normal maintenance, fuel, public transportation, parking and tolls
OTHER EXPENSES: Childcare, alimony and child support, school, medical co pays, deductibles, prescriptions
OTHER SECURED DEBT: (total monthly payments)

TOTAL MONTHLY EXPENSES:

DISPOSABLE INCOME:

(Total income minus Total Expenses)

 

The representative that I am working with is: (please check one)

Michael

Sarah

 Dennis Erin no prior contact    

Please fill in today's date

before clicking submit:

  

     (Please only click the submit button one time, it will take a few seconds to process)