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What is Your Zip Code? *

Do You Have Any Debts? *

None

Garnished Wages

Parking Tickets or Toll Way Fines

Taxes or Other Government Related Debt

Creditor Harassment Due to Unpaid Bills

Behind on Car or House Payments

Child Support or Student Loans

Other

How Many Credit Cards Do You Have? *

0

1

2

3

More than 3

Do You Own Real Estate? *

Yes

No

Have you filed for bankruptcy in the last 8 years? *

Yes

No

Are you currently employed? *

Yes

No

What is your monthly average income? *

$0 - $1,500

$1,500 - $3,000

$3,001 - $4,500

More than $4,500

What is your total household monthly income? *

$0 - $1,500

$1,500 - $3,000

$3,001 - $4,500

More than $4,500

Do you have any other types of income? *

None

Social Security, Pension, or Retirement Income

Child Support or Alimony income

Unemployment or Other Government Assistance

Rental Income

Personal Business Income

What is the amount of non-employment household income? *

$0 - $1,500

$1,500 - $3,000

$3,001 - $4,500

More than $4,500

Do you have any of the following bank accounts? *

None

Checking Account

Savings Account

Online Debit Card

Do you have any of the following? *

None

Stocks and Bonds

401K or IRA

Pension

Other

Full Name *

Email *

Phone *

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