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

Bank	Balance	Min. Payment	Interest Rate

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TOTAL AMOUNT OWED (add all balances from list of creditors above):	$
ESTIMATED MONTHLY PAYMENT TO CCDCS**: [Total Amount Owed] x 2.3% =	$
By paying 2.3% of this debt, your payoff will be in approximately 4-5 years. ** These estimates assume a reduction in interest rates.

Mortgage/Rent:	$
Food / Grocery:	$
Gas & Electric:	$
Auto Fuel / Oil:	$
Car Payments:	$
Cable TV / Internet:	$
Tithing / Donations:	$
Support Payments:	$
Childcare:	$
Telephone:	$
Clothes (buy/clean):	$
Medical (non-insurance):	$
Life Insurance:	$
Health / Dental / Vision Insurance:	$
Home / Renters Insurance:	$
Auto Insurance:	$
School Tuition:	$
Beauty / Barber:	$
Home Maintenance:	$
Entertainment:	$
Tobacco:	$
Soda / Alcohol:	$
Miscellaneous:	$
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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