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Debt Relief Harold's Story

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Qualifying Questionnaire

Please fill out and submit or print and mail the following questionnaire to determine if you qualify for our debt negotiation or credit restoration services.

3. Months Behind

3. Payment

3. Balance

2. Months Behind

2. Payment

2. Balance

2. Creditor

1. Months Behind

1. Payment

1. Balance

1. Creditor

Total: Payment:

Other: Months Behind:

Other: Value of Property:

Other: Payment:

Other: Balance:

Taxes: Value of Property:

Taxes: Payment:

Taxes: Balance:

Stud. Loans: Months Behind:

Stud. Loans: Value of Property:

Auto 2: Months Behind:

Stud. Loans: Payment:

Stud. Loans: Balance:

Auto 2: Payment:

Auto 2: Balance:

Auto 1: Months Behind:

Auto 1: Value of Property:

Auto 1: Payment:

Auto 1: Balance:

Mortgage 2: Months Behind

Mortgage 2 Value of Property:

Mortgage Payment 2:

Mortgage 2 Balance:

Months Behind 1:

Value of Property 1:

Payment 1:

Balance 1:

Client(s) Name:

Address:

City:

State:

Zip Code:

Phone:

Electricity:

Trash:

Doctors Co-Pay:

Work/School: Lunch

Sewer/Water:

Gas/Oil - Hm:

Food/Groceries:

Life Insurance:

Child Care:

Cable:

Dining Out:

Medications:

Car Insurance:

Tuition/School Fees:

Medical Equipment:

Gasoline:

Business Expenses/Union Dues:

TOTAL:

Gross/Month:

Total Expenses/Rent/Secured Payments:

Net Income/Month:

Income Left:

Deductions for Loans and Retirement:

Home Rent:

Auto Rent:

Other Rent:

TOTAL:

Mortgage 1:

Mortgage 2:

Auto 1:

Auto 2:

Stud. Loans:

Taxes:

Other:

How did you find us?

If selected other please list here:

Phone:

Cell:

Internet:

Entertainment:

Clothing:

Health Insurance:

Dental Insurance:

Dental Co-Pay:

Veterinary:

Clubs, Sports & Hobbies

Auto Expenses:

Taxi/Parking/Public Transportation:

Contribution

Child Support:

Beauty/Barber/Nails/Dry Cleaning:

Other (Holidays, Birthday, Cigarettes, etc.:

Best Time to Call:

Auto 2: Value of Property:

Taxes: Months Behind:

Total: Balance:

3. Creditor

Creditor

Balance

Payment

Value of Property

Months Behind

TOTAL:

Creditor

Balance

Payment

Months Behind

Secured Debt

Unsecured Debt

Rent

Living Expenses