800-579-2414

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Debt Management Program Registration

REGISTRANT INFORMATION

Enter Full Legal Name and Address:

Joint REGISTRANT INFORMATION

Enter Full Legal Name and Address:

First Name:

Middle Name:

Last Name:

Address:

City:

State:

Zip:

Home Tel:

Cell Phone:

Email:

Last 4 digits of SSN:

First Name:

Middle Name:

Last Name:

Address:

City:

State:

Zip:

Home Tel:

Cell Phone:

Email:

Last 4 digits of SSN:

List of Unsecured Debts

Please round amounts to the nearest dollar.

Creditor Name

Past Due?
Click if
Yes

Current
Balance

Current
Payment

Current
Interest
Rate

Past Due
Amount

%

%

%

%

%

%

%

%

%

%

%

%

%

%

%

%

%

%

%

%

Totals:

Monthly Income

Please enter amounts as a whole dollar. ex: "$1255.38" should be entered as "1255"

Salary 1:

Salary 2:

Second Job 1:

Second Job 2:

Total Income:

Child Supp/ Alimony:

Social Security:

Monthly Expenses

Sub Total - Home:

Rent:

Mortgage:

2nd Mortgage:

Property Tax / Ins.:

Maint. & Repairs:

Yard Equip/Care:

Renter's Insurance:

Sub Total - Utilities:

Electricity:

Gas/firewood:

Water/Water Softener:

Trash:

Basic Phone:

Long Distance:

Cell phone/pager:

Sub Total - Household:

Groceries:

Supplies:

Healthfood/Vitamins:

Diapers/formula:

Life/Disab. Insur.:

Laundry:

Dry Cleaning, Carpet:

Pet Food,Vet,Groom:

Postage/Shipping:

Childcare:

Child Support:

Alimony:

Sub Total - Auto:

Payment 1:

Payment 2:

Insurance:

Fuel 1:

Fuel 2:

Tires 1:

Tires 2:

Oil 1:

Oil 2:

Repair/Maint. 1:

Repair/Maint. 2:

Tax/Lic 1:

Tax/Lic 2:

Car Washes:

Sub Total - School:

School Lunches:

Tuition:

Books:

Supplies:

Activities:

Sub Total - Misc:

Retirement:

Rental Property:

Food Stamps/Other:

Sub Total - Medical:

Med/Dent/Eye Insur.:

Doctor/Chiro/Derm:

Dentist/Ortho:

Prescriptions:

Glasses/Contacts:

Sub Total - Personal:

Allowances - Adults:

Allowances - Kids:

Hair/Nails/Makeup:

Clothing - Adults:

Clothing - Kids:

Jewelry:

Lessons:

Memberships/Dues:

Tobacco:

Wine/Beer/etc.:

Subscriptions:

Sub Total - Recreation:

Work Lunches:

Eating out:

Cable TV:

Movies:

Video:

Internet:

Vacation/Outings:

Photos/Hobbies:

Music/CDs:

Books/Yearbooks:

Sports/Camps:

Sub Total - Savings:

Retirement:

Regular Savings:

Emergency Fund:

Sub Total - Donations:

Tithes:

Offerings:

Sub Total - Gifts:

Christmas:

Birthdays:

Holid, Anniv, Cards:

Sub Total - Debts:

Student Loans:

Medical Bills:

Installment Loans:

IRS:

Credit Cards:

Collection:

Summary:

Total Income:

Total Expenses:

Net Available:

Assets / Liabilities

Real Estate:

Mortgage:

2nd Mortgage:

Auto:

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