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July 21, 2015

Initial Contact Application


General Information























Housing Information






Utilities

Transportation
Vehicle Make/Model  Lease or Own? Monthly Payment 
#1
#2
#3
Groceries and Household Items
Medical and Insurances




Dependents

Miscellaneous Items
This includes tithing, gym memberships, eating out, clothing, etc.
Credit Cards 
Credit Card Issuer Balance Payment APR
Other Loans
Please include any unsecured loans or student loans here:
Lender Balance Payment APR
Income
Monthly Income
Monthly Take Home Pay:
Co-Client's Monthly Take Home Pay:
Monthly Retirement or Pension:
Alimony or Child Support Income:
Social Security Income:
Disability Benefits or SSI:
Public Assistance (Food Stamps):
Unemployment Benefits:
Co-Client's Unemployment Benefits:
Other Income (Part Time Job / Overtime / Bonuses / Commission):

Assets
Total Value:
What is the value of your home (if you own)?
What is the value of your vehicle(s) (if you are financing/own)?
How much cash do you currently have on hand?
What is the current balance in your checking/savings account?
What is the current value of your retirement savings (i.e. 401K)?
What is the current value of any other assets?
Liabilities
Total Amount Owed:
What is your mortgage balance (if you own)?                                      
What is the balance on your auto loan(s) (if you are financing)?
What is the balance of any additional liabilities you may have?
Reason you are seeking assistance





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