If you are a human and are seeing this field, please leave it blank. Fields marked with a * are required. I. Contact Information First Name * Last Name * Date of Birth * Spouse First Name Spouse Last Name Spouse Date of Birth Address 1 * Address 2 City * State * Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware District of Columbia Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampsire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming Zip / Post Code * Home Phone * Cell/Daytime Phone * Your Email * Spouse Email II. Income Information Gross Monthly Amount Net Monthly Amount Your Occupation Job#1 * Gross Amount Job #1 * Net Amount Job#1 * Your Occupation Job#2 Gross Amount Job #2 Net Amount Job#2 Spouse Occupation Job#1 Spouse Gross Job#1 Spouse Net Job#1 Spouse Occupation Job#2 Spouse Gross Job#2 Spouse Net Job#2 Totals Total Gross Income Total Net Income III. Monthly Income and Expense Record Enter Monthly amounts, not Annual Expense Monthly Payment 1st Mortgage/Rent 2nd Mortgage Property Taxes (if not included in mortgage) Homeowner's Insurance (if not included in mortgage) Association Dues Energy (gas/oil/electric) Water/Sewage Phone/Cell Phone Home Maintenance Life Insurance Car Insurance Student Loan Debt Car Loan Car Repair/Maintenance Food/groceries/fast food/restaurant Gasoline/transporation/parking Medical (doctor, dentist, eye care, prescriptions) Daycare, babysitters Cable TV/Internet Educational expenses (including tuition and books) Church/religious donations Personal (hair, clothes) Cigarettes/beverages (including alcohol) Christmas/Gifts Entertainment/Hobbies/Sports Other Expenses Total Monthly Expenses Total Monthly Income Deduct Monthly Expenses from Income IV. Debt Analysis Please complete the debt information. You should include all consumer debts. Include the issuing bank for all Visa and Mastercard debts. Example: Creditor/Collection Agency Balance Payment ABC Collection Allied Collection Chase Bonton 3000 4000 2500 350 0 200 25 10 Creditor/Collection Agency Balance Payment Total Outstanding Balance If you choose our debt management plan (DMP), your payment could be Why are you completing this application? BankruptcyDebt Management (PA Residents Only)Budget CounselingCredit Report ReviewHousingStudent Loan Debt Enter the answer in the box as a number. What is fifteen minus seven? Anti-Spam * Click the Submit button when finished. If you do not see the "Success" message, please check to see that you have completed all of the required items. "This is a Required Field" will appear beneath items that are missing.