name
address
city and state
county
cell
work
e-mail
Do you have a lump sum of money
available to settle
your debt?
Yes
No
Please describe any significant
assets you have:
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What is your current
monthly net income?
you
spouse
If you own a home,
what is it’s value?
Mortgage
What was your most current AGI
(Adjusted Gross Income) on your tax return?
Enter the Current Amount of Unsecured
Debt (Credit Cards, Med Bills, Signature Loans,
Payday Loans, etc... Loans without collateral)
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