Program Enrollment Form

(*) Denotes Required Field

Salutation:	Mr. Ms. Mrs. Miss Dr.
First Name(*):
Last Name(*):
Address(*):
City(*):
(*) State:	Select Your State Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware District Of Columbia Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming
(*) Zip Code:
(*) E-mail Address:
(*) Home Phone:	Area Code     Phone Number
(*) Work Phone:	Area Code     Phone Number   (Ext. #)
I prefer to be contacted at my home number  work number.
Best time to call:	Early Morning Late Morning Early Afternoon Late Afternoon
(*) What is the total amount of your unsecured debts?	$2,500 - $5,000 $5,000 - $10,000 $10,000 - $20,000 $20,000 - $40,000 $40,000 - $60,000 $60,000 - $80,000 $80,000 - $100,000 Over $100,000
Please list all unsecured debt in the table below: Creditor Name Account Type Payment Amount Due Current Balance Collections Legal Line of Credit Medical Personal Loan School Loan Store Credit Card Tax Utilities Visa/MC Other Collections Legal Line of Credit Medical Personal Loan School Loan Store Credit Card Tax Utilities Visa/MC Other Collections Legal Line of Credit Medical Personal Loan School Loan Store Credit Card Tax Utilities Visa/MC Other Collections Legal Line of Credit Medical Personal Loan School Loan Store Credit Card Tax Utilities Visa/MC Other Collections Legal Line of Credit Medical Personal Loan School Loan Store Credit Card Tax Utilities Visa/MC Other Collections Legal Line of Credit Medical Personal Loan School Loan Store Credit Card Tax Utilities Visa/MC Other Collections Legal Line of Credit Medical Personal Loan School Loan Store Credit Card Tax Utilities Visa/MC Other Collections Legal Line of Credit Medical Personal Loan School Loan Store Credit Card Tax Utilities Visa/MC Other Collections Legal Line of Credit Medical Personal Loan School Loan Store Credit Card Tax Utilities Visa/MC Other Collections Legal Line of Credit Medical Personal Loan School Loan Store Credit Card Tax Utilities Visa/MC Other
Have you ever filed bankruptcy? If so, approximate date (MM/YY):	Yes   No
Average annual IRS refund amount for the last three years?
Recent Garnishments? If so, approximate date (MM/YY):	Yes   No
Recent law suit or legal action? If so, please explain nature of legal action:	Yes   No
Briefly explain your reasons for applying for our Debt Management Program:
Net Monthly Income (Include all after-tax household income):
Total Monthly Expenses (Include all household expenses excluding credit card payments):
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