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Name*	first name last name
Address
City
State* / Zip
Home Phone*
Work Phone
Fax
E-Mail*
What is the best way to contact you	Morning at Home Morning at Work Afternoon at Home Afternoon at Work Evening at Home Evening at Work
Are payments current or behind?	Current Behind
What is the total amount of your unsecured debt?*	choose one $5,000-10,000 $10,001-20,000 $20,001-30,000 $30,001-40,000 $40,001-50,000 $50,001-60,000 $60,001-70,000 $70,001-80,000 $80,001-90,000 $90,001-100,000 $100,000+

For credit card accounts please specify the bank name.

1st Creditor Account Name: Type: Credit Card Department Store Bank Loan Furniture Loan Medical Bills Taxes Utilities Other Balance: $ Minimum Payment: $

2nd Creditor Account Name: Type: Credit Card Department Store Bank Loan Furniture Loan Medical Bills Taxes Utilities Other Balance: $ Minimum Payment: $

3rd Creditor Account Name: Type: Credit Card Department Store Bank Loan Furniture Loan Medical Bills Taxes Utilities Other Balance: $ Minimum Payment: $	4th Creditor Account Name: Type: Credit Card Department Store Bank Loan Furniture Loan Medical Bills Taxes Utilities Other Balance: $ Minimum Payment: $

5th Creditor Account Name: Type: Credit Card Department Store Bank Loan Furniture Loan Medical Bills Taxes Utilities Other Balance: $ Minimum Payment: $

6th Creditor Account Name: Type: Credit Card Department Store Bank Loan Furniture Loan Medical Bills Taxes Utilities Other Balance: $ Minimum Payment: $

7th Creditor Account Name: Type: Credit Card Department Store Bank Loan Furniture Loan Medical Bills Taxes Utilities Other Balance: $ Minimum Payment: $

8th Creditor Account Name: Type: Credit Card Department Store Bank Loan Furniture Loan Medical Bills Taxes Utilities Other Balance: $ Minimum Payment: $

9th Creditor Account Name: Type: Credit Card Department Store Bank Loan Furniture Loan Medical Bills Taxes Utilities Other Balance: $ Minimum Payment: $

10th Creditor Account Name: Type: Credit Card Department Store Bank Loan Furniture Loan Medical Bills Taxes Utilities Other Balance: $ Minimum Payment: $

11th Creditor Account Name: Type: Credit Card Department Store Bank Loan Furniture Loan Medical Bills Taxes Utilities Other Balance: $ Minimum Payment: $

12th Creditor Account Name: Type: Credit Card Department Store Bank Loan Furniture Loan Medical Bills Taxes Utilities Other Balance: $ Minimum Payment: $

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