Got Debts?
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Congratulations on making the right choice. 
Please fill out the following form completely.
Use the <TAB> key to move between fields.
Please list total unsecured debt for example: credit cards, medical bills, personal unsecured loans etc.

Estimated time to complete form: less than 3 minutes.

Name
Address
City
State
    Zip
Home Phone
Work Phone
E-Mail

Please be sure to enter your complete e-mail address. A proper email address should contain your name, an @ and name of domain for ex: info@freeservice.com, help@aol.com, sally@yourdomain.net etc.

End of Part 1. Continue for Part 2.

You my wish to gather all your bills at this point. Please list your unsecured debt (credit cards, medical bills, personal signature loans from accredited lending companies, old utility bills etc.) Do not list secured debts such as car payments (repo's ok), mortgages, current utilities, court ordered payments like alimony or child support. When listing creditors make sure you list each individual creditor ex. City Bank Visa or Wells Fargo Mastercard not just Visa or Master Card. When listing medical bills list each individual doctor, clinic or hospital.

Creditor
Amount Owed
Monthly Payment
Months Behind
Purpose of Debt
Creditor
Amount Owed
Monthly Payment
Months Behind
Purpose of Debt
Creditor
Amount Owed
Monthly Payment
Months Behind
Purpose of Debt
Creditor
Amount Owed
Monthly Payment
Months Behind
Purpose of Debt
Creditor
Amount Owed
Monthly Payment
Months Behind
Purpose of Debt
Creditor
Amount Owed
Monthly Payment
Months Behind
Purpose of Debt
Creditor
Amount Owed
Monthly Payment
Months Behind
Purpose of Debt
Creditor
Amount Owed
Monthly Payment
Months Behind
Purpose of Debt
Creditor
Amount Owed
Monthly Payment
Months Behind
Purpose of Debt
Creditor
Amount Owed
Monthly Payment
Months Behind
Purpose of Debt

If you have additional bills, submit the current application and then resubmit the rest. Be sure to include your name on any additional submissions. Please submit each list of creditors one time only. It may take a few moments to transmit so please be patient. Please, serious inquiries only. Incomplete or frivolous forms will be discarded. 
This form is for those who are serious about handling their bills in a responsible manner.

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