Client Name:
Street Address:
City, State, Zip Code:
Email Address:
Home Phone:
Work Phone:
Other Phone:
Date of Birth:
Social Security Number:
Employer:
Years Employed:
Net Income:	$
Other Income Source:	$
Spouse Name:
Date of Birth:
Social Security Number:
Employer:
Years Employed:
Net Income:	$

Creditor	Account No.	Owner	Balance	Payment	Interest Rate	Past Due Amount

TOTAL AMOUNT OWED (from above):	$
TOTAL DEBT FOR CONSOLIDATION: [Total Amount Owed] x 2.3% =	$
DEBT CONSOLIDATION:  Estimated Payment*:	$
By paying 2.3% of this debt, your payoff will be in approximately 4-5 years. Call a certified credit counselor at CCDCS to get an exact payoff date. * These estimates assume a reduction in interest rates.
CHOOSE PAYMENT DATE: (Payment MUST be received by end of chosen date.)	10th of each month 20th of each month 30th of each month

Mortgage:	$
Food / Grocery:	$
Utilities:	$
Auto Fuel / Oil:	$
Other Transportation:	$
Car Payments (specify):   $   $   $
Tithing / Donations:	$
Support Payments:	$
Childcare:	$
Telephone:	$
Clothes (buy/clean):	$
Medical (non-insurance):	$
Life Insurance:	$
Health / Dental / Vision Insurance:	$
Home / Renters Insurance:	$
Auto Insurance:	$
School:	$
Union / Club Dues:	$
Beauty / Barber:	$
Home Maintenance:	$
Entertainment:	$
Hobbies:	$
Tobacco:	$
Soda / Alcohol:	$
Cable TV:	$
Internet Service:	$
Gifts:	$
News / Books / Magazines:	$
Miscellaneous (specify):   $   $   $
TOTAL MONTHLY LIVING EXPENSES:	$
TOTAL NET INCOME:	$
AMOUNT AVAILABLE FOR DEBT REDUCTION:	$
After you have completely filled out this form, please click on the "submit" button below. A certified credit counselor will be contacting you shortly to discuss the specifics of your particular plan.
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