To determine if Credit Counselors Corp. will be best for you, please fill in
the appropriate information. A CCC Counselor will contact you by the
next business day (9-6 Mon-Wed, 9-7 Thur-Fri, 9-Noon Sat) All information
is handled confidentially.
Best Time To Contact:
Name:
*
SSN:
Spouse:
SSN:
Address:
E-mail:
*
City:
State:
Zip:
Home phone:
*
FAX:
Employer1:
Phone:
Employer2:
Phone:
Monthly take home pay
* Services not available to New York
State, Michigan and California residents.
Spouse's monthly take home pay
Other income
................................................................................................
Living Expenses
Rent/Mortgage:
Groceries:
Electricity:
Heat:
Water:
Cable:
Telephone:
Car Ins.:
Other:
..............................................................................
Client Debt Information
Fill in the Debt Summary using the information from your MOST CURRENT statements.
Account Name(including mortgage & car loans)
Monthly Payment
Last Time Paid
Current Balance
Interest Rate
(example)Citibank Visa
July 97
$1560.00
19%
1-800-937-9030 ::
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