Your Name:

Address:

City:

State:

Zip:

Telephone:

Fax:

E-mail:

Do you have a good income but feel overwhelmed by your bills
YesNo

Do you juggle other bills to keep up the minimum monthly payments on credit cards?
YesNo

Have you reached the credit limit on any of your credit cards?
YesNo

Do you charge items you once bought with cash?
YesNo

Are you paying late fees?
YesNo

Is your current job barely making ends meet?
YesNo

Have you taken money from your savings account to pay your credit card bills?
YesNo

Have you ever contemplated filing bankruptcy?
YesNo

Would you like to have your finance charges stopped or reduced?
YesNo

Are you making your auto payment at the end of the grace period?

YesNo

If you answered yes to two or more of these statements Click on to fill out an application using information from your most current statements, then click on Submit.