Prefix *

Mr.

Mrs.

Ms.

Social Security Number *

Copy of Driver's License/ID

What county do you currently reside in? *

Have you lived in the county listed above for the last 5 years?

What other city, state, counties have you lived in the last 5 years?

Do you have access to the finalized settlement agreement or dissolution of marriage documents so you can provide them to us?

Do you share any debts with a current or previous spouse?

Please provide more detail regarding the debts that you share with your current or previous spouse.

What language do you speak most often? *

Are you a veteran or currently serving in the military? *

Please provide more detail in regards to what branch of military, dates served, rank, and deployment.

What is the fastest way to get in touch with your? (call, text, or email) *

What is your current monthly income from all sources? *

What do you (or did you) do for a living? *

Are you currently employed? *

How long have you been employed?

Most Recent Employer

When were you last employed?

How long were you previously employed?

Is/was it full-time or part-time? *

Do you receive any additional income from Social Security? *

How much do you receive monthly from Social Security?

Do you receive any additional income from a pension? *

How much do you receive monthly from your pension?

What is the source of your pension?

Do you receive any additional income from disability benefits? *

How much do you receive monthly in disability benefits?

Can you share more details, including when you started receiving benefits and when you anticipate returning to work?

Do you receive any additional income from worker's compensation? *

How much do you receive monthly in worker's compensation?

Do you have an expected timeframe or details about a return to work? Please provide more detail.

Do you receive any additional income from retirement? *

How much do you receive monthly from your retirement?

Do you receive any additional income from alimony payments? *

How much do you receive monthly in alimony payments?

Do you receive any additional income from child support payments? *

How much do you receive monthly in child support payments?

Do you have any other sources of income that aren't listed? *

Please provide more details regarding the additional source of income.

Expense Overview

Let's discuss your monthly expenses. If you are unsure of the exact amount, an estimate is fine.

Do you owe any IRS or state taxes, including back taxes? *

How much do you currently owe in taxes? Provide as much detail as possible.

Do you currently pay a rent or mortgage? *

How much is your monthly mortgage payment?

How much do you pay monthly in rent?

If you currently pay a mortgage, how much is your current loan balance?

If you currently pay a mortgage, how much is the estimated value of your home?

Are you currently paying homeowner's or renter's insurance?

How much is your monthly payment for homeowner's or renter's insurance?

How are you currently covering housing expenses?

What are your average monthly utility costs for electricity? *

What are your average monthly utility costs for water? *

What are your average monthly utility costs for natural gas? *

How much to you pay monthly for life insurance?

Do you have an internet or cable bill? *

How much do you pay monthly on internet and/or cable?

How much is your monthly cellular bill? *

Additional costs for subscriptions. List below.

Do you have a monthly car payment? *

How much is your monthly car payment?

How much do you spend monthly on gas for your vehicle?

How much is your monthly car insurance payment?

Are you paying for medical insurance? *

How much is your monthly payment for medical insurance?

Do you have ongoing expenses for prescriptions or medications? *

How much are you spending monthly for prescriptions or medications?

Are these related to any specific medical conditions? If so, please provide more detail.

What are your average monthly costs for childcare? *

Are you currently making payments on other credit cards or prior settlements? *

Please provide the amount being made in payments and more details regarding these payments.

Do you have any court-ordered payments such as alimony or child support? *

How much are you paying in alimony or child support? Please provide more detail.

Are there any outstanding hospital or medical billls? *

Can you provide more details about any hospital stays that led to these expenses?

How many dependents do you currently support? *

What is your monthly food budget? *

Credit & Financing

Do you have a credit monitoring service? *

What service do you use?

Have you reviewed your credit within the last year?

If we provide you with a copy of your credit report, are you willing to review it for any errors and/or inaccuracies?

When can we review it together?

Do you recall there being anything wrong or incorrect on your credit report when you reviewed it last?

Please describe the wrong or incorrect information in your credit report.

Since finding the error in your credit report, have you applied for a mortgage, credit card, auto loan, or other type of financing?

Were you denied for credit at that time?

Have you tried to dispute the error on your credit report with the credit bureaus and/or the business reporting the incorrect information?

Please provide more details in regards to how and when you attempted to dispute the inaccuracies in your credit report. Please provide as much detail as possible.

Are any of the accounts that you want to enroll in our program related to the purchase or financing of a vehicle or piece of equipment? *

What kind of vehicle or piece of equipment? (Please provide as much information as possible. Make, model, color, serial number, etc. If titled, the name on the title.)

Are you still in possession of the vehicle or piece of equipment?

Are you aware that if you stop paying the debt related to a vehicle or piece of equipment, that you may have to return it or it could be repossessed?

Aside from your ability to pay, have you experienced any issues with the vehicle or piece of equipment? Please provide more detail.

Was the vehicle or piece of equipment returned or repossessed?

Have you received any correspondence from the Creditor or Seller regarding the vehicle or piece of equipment?

Did you receive a notice from the Creditor within 15 days of them taking possession of the vehicle or piece of equipment?

Can you provide us with a copy of the notice from the Creditor regarding the repossession of the vehicle or piece of equipment?

Please upload the notice that you received from the Creditor regarding the repossession of the vehicle or piece of equipment.

Have you received any documentation related to that vehicle or piece of equipment and/or the lender or sellers intent to sell or otherwise dispose of the vehicle or piece of equipment?

Are any of the accounts that you want to enroll in the program related to your current or previous home and/or materials purchased for or work done on your home? *

Please provide more detail regarding the accounts related to your home.

Have you been sued or received a judgment against you for any of the accounts that you want to enroll in the program? If yes, please explain. *

Have you received notice of any pending court dates for any of the accounts that you want to enroll in the program? If yes, please explain. *

Were any of the accounts that you want to enroll subject to any fraud or identity theft? If yes, please explain. *

Are any of the accounts that you want to enroll in the program related to the purchase and/or installation of solar panels? If yes, please provide more details. *

Collections & Creditors

Have you communicated with your creditors regarding your current financial situation in an attempt to negotiate a reduced payment or forbearance? If yes, Please provide more details. *

Have you received notification from any of your creditors regarding any of the accounts being "charged off" and/or transferred to collections? If yes, please provide more details. *

Have you been contacted in any way by a collection agency or third-party debt buyer? If yes, please provide more details. *

Have any of your creditors or collectors engaged in any of the following:

Contacted you at work

Spoken to others about your debt

Contacted you before 8am or after 9pm

Contacted you after you wrote them a letter to cease all communication

Used threats or profane language

Failed to disclose their identity or who they were calling on behalf of

Used logos or documents that led you to believe they were the US government

Implied that your non-payment could result in your arrest

Used any other deceptive tactics as an attempt to collect

Reason for Non-Payment

In this section, please share as much as you can about the reasons why you've fallen behind on payments. Take your time, and feel free to share as much as you’re comfortable. The more detail you can provide, the better positioned we’ll be to fight for the best possible outcome on your behalf. Your story is critical in helping us build a strong case for negotiation.

Please briefly explain your hardship: how it began, what transpired, and how it resulted in financial difficulty. Include all major events such as loss of income, hospitalization, death, or other contributing factors.

Was it due to job loss or financial instability?

Have rising interest rates on credit cards or loans made payments unaffordable?

Were medical expenses or accidents a factor?

Were there any cases of fraud or unexpected financial hardships?

Settlement Payment Preferences

Let’s discuss your preferences for settlement payments. Keep in mind, this is information to help us understand how to best help you and this information is discussion purposes only.

Would you prefer a one-time lump sum payment or are you more comfortable with monthly installments? *

Considering your budget and other debts, how much can you comfortable allocate towards a monthly payment?

Any additional notes or information to add before submitting?

General Information

Income Details

Expense Overview

Credit & Financing

Collections & Creditors

Reason for Non-Payment

Settlement Payment Preferences