Debt Relief. . . Enrollment Form~
This form is used to get preliminary information and does not enroll you into any program and does not signify any obligation on your part. The information will allow us to determine your eligibility and calculate the best plan we can offer.

We have both Debt Settlement and Debt Management for you to choose from to deal with your unsecured credit accounts. These 2 distinct programs are the Solution Options beyond Paying Creditor Direct.

If you decide to move forward with enrollment in a program, we will be getting more detailed information before an official application is furnished for your review, approval and signature.

Instructions & Form below Site Logo

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Free Quote   Free Counseling   Financial Analysis    Contact Us

www.counselingdebtsolutions.com
1-800-457-5173
Office Open (days, evenings, week-ends) Pacific Time Zone
Owner/Manager: Ann H Noel-Eager

Instructions for Form

To Use Form:

  • You may print this web page:

    • ~ OR ~

  • You may copy and paste page in an e-Mail or Word processing document. You will want to open your e-Mail program or Word processing program. Create new e-Mail message or Word document and minimize it in taskbar.
  • Then follow these steps:

    • You should have an e-Mail or Word document with all information from this page!

    ~ OR ~

    You can hold down left mouse button and scroll over text to highlight; copy (Ctrl+C); paste (Ctrl+V) onto blank e-Mail or Word document.

    If none of these work, Contact Us and we would be glad to send a copy by fax or e-Mail. Also, you may call 1-800-457-5173 for us to take the form information by phone.

    Thank You!

    Information Form~

    Name (Applicant):
    Co-Applicant:

    Expenses List~
    Only list a cost below if it is a monthly out-of-pocket expense and not taken from your employment check or included in mortgage. These can be estimates but try to come as-close-as-possible to give us the best information.

    Expenses:

    Mortgage Payment: Rent Payment: Groceries:
    Homeowners Ins: Rent Insurance: Dining Out:
    Cable/TV/Internet: Telephone: Cell Phone:
    Auto Pmt: Auto Pmt: Clothes:
    Auto License: Gas, Oil, Repairs: Other Auto:
    Hair/Beauty: Subscriptions: Laundry/Household:
    Drs/Dentists: Medication: Optometrist:
    Entertainment: Subscriptions: Club Dues/Hobbies:
    Alimony: Child Care: Child Support:
    Donations: Other: Other:

    Creditor List~
    Please list all accounts that are open to include: Credit Cards, Gas Cards, Store Accounts, Repossessions, Finance Company, Loans, Old Utilities, Contracts, Student Loans & Other.

    Unsecured Creditor List:

    Creditor: Creditor: Creditor:
    Account #: Account #: Account #:
    Current Balance: Current Balance: Current Balance:
    Monthly Payment: Monthly Payment: Monthly Payment:
    Interest Rate: Interest Rate: Interest Rate:
    Name(s) on Acct: Name(s) on Acct: Name(s) on Acct:
    Months Late: Months Late: Months Late:
    Creditor: Creditor: Creditor:
    Account #: Account #: Account #:
    Current Balance: Current Balance: Current Balance:
    Monthly Payment: Monthly Payment: Monthly Payment:
    Interest Rate: Interest Rate: Interest Rate:
    Name(s) on Acct: Name(s) on Acct: Name(s) on Acct:
    Months Late: Months Late: Months Late:
    Creditor: Creditor: Creditor:
    Account #: Account #: Account #:
    Current Balance: Current Balance: Current Balance:
    Monthly Payment: Monthly Payment: Monthly Payment:
    Interest Rate: Interest Rate: Interest Rate:
    Name(s) on Acct: Name(s) on Acct: Name(s) on Acct:
    Months Late: Months Late: Months Late:
    Creditor: Creditor: Creditor:
    Account #: Account #: Account #:
    Current Balance: Current Balance: Current Balance:
    Monthly Payment: Monthly Payment: Monthly Payment:
    Interest Rate: Interest Rate: Interest Rate:
    Name(s) on Acct: Name(s) on Acct: Name(s) on Acct:
    Months Late: Months Late: Months Late:
    Creditor: Creditor: Creditor:
    Account #: Account #: Account #:
    Current Balance: Current Balance: Current Balance:
    Monthly Payment: Monthly Payment: Monthly Payment:
    Interest Rate: Interest Rate: Interest Rate:
    Name(s) on Acct: Name(s) on Acct: Name(s) on Acct:
    Months Late: Months Late: Months Late:

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    Site last updated January 21, 2005
    (please e-Mail us if you have a problem with navigation)
    Thank You!