Confidential Business Debt Review Form

Thank you for reaching out to explore debt restructuring options. This confidential intake

form helps our specialists better understand your current financial situation so we can

evaluate potential solutions for your business. Please complete the form as accurately as

possible.

Business Information

Company Name

Business Address

City

State

Zip code

Primary Contact Information

Full Name

Best Phone Number

Best Email Address

Debt Information

What types of debt are you currently dealing with?

Approximate Total Amount of Debt

Approximately How Many Creditors Do You Have?

Current Financial Situation

How Much Can You Realistically Afford to Pay Toward These Debts Each Month?

Do You Currently Have Any Judgments Against You or the Business?

Yes

Are There Any Active Lawsuits Related to These Debts?

Yes

Are Any Accounts Currently in Collections?

Yes

Goals & Concerns

What Is Your Biggest Financial Concern Right Now?

What Outcome Are You Hoping to Achieve Through Debt Restructuring?

Have You Worked With Another Debt Resolution Company Before?

Yes

CONSENT & SUBMISSION

I understand this submission is confidential and does not guarantee acceptance into our debt restructuring or negotiation program. I authorize a representative to contact me regarding available solutions.