How much? No
How much? No
How much? No
How much? No
How much? No
How much? No
How much? No
How much? No
How much? No
Public transportation
No
No Rent
No
Please answer the questions below to the best of your ability. If you do not know the amount, a best estimate will suffice. 1. Do you have money in the bank, including cash on hand? Yes 2. Do you have any retirement account(s)? Yes
5. Do you have any personal loan(s)? Yes
9. What is your monthly income (after taxes and any deductions)? 11. How much do you spend on utilities (typical monthly average)? 12. How much do you spend on food (typical monthly average)? 10. Do you currently use a vehicle or utilize public transportation? 6. Do you have any credit card debt(s)? Yes
7. Do you have any medical debt(s)? Yes
13. Do you have medical/health/dental insurance Yes How much? No 14. Do you have out of pocket medical expenses? Yes 15. Are you currently making monthly debt payments on any of the following? (check all that applies) 8a. Do you have student loan(s)? Yes
8b. Do you have tax debt(s)? Yes
Yes
Vehicle
8c. Do you have debt(s) other than 10a and 10b?
payments not deducted from your paycheck?
8. Do you have any other debt(s)? Yes
If you answered yes to item 8:
3. Do you own your home? Yes
4. Do you own vehicle(s)? Yes
If you answered yes to item 3:
If you answered yes to item 4:
3a. What is the current market value of your home? 3b. What is the current mortgage balance?
4a. What is the current market value of your car?
4b. What is the car loan balance?
4c. Do you have other vehicle(s) Yes No
Credit card Yes No Personal loan Yes No Student loan Yes No Other debts Yes No
Alimony Yes No Child support Yes No Tax debts Yes No Divorce Unemployment
Below are some of the common reasons why people find themselves in financial hardship. Please select all that applies to you:
Current Financial Situation
"PLEASE CONTINUE ONLY IF YOU ARE TAKING THE CREDIT COUNSELING COURSE." Client Name Phone Number
Poor financial management Death in the family
Gambling Reduced work hours
Overspending Other Please explain
Personal injury Serious illness