Application for Credit Counseling

Personal

Application for Credit Counseling

Name: First

Date of Birth:

Spouse Name:

(If filing jointly)

First

Date of Birth:

Telephone Number:

Fax Number:

Address: Street

City

Middle

Last

Social Security Number:

Middle

Last

Social Security Number:

Telephone Number: Email Address:

State

Zipcode

Attorney's Name: Phone Number: Fax Number:

Attorney

Payment

$29.95 for Single / Joint (Online & Telephone Version)

Fees may be in the form of money orders or credit/debit card. If paying by credit/debit card, please complete the form below.

Circle Card Type: Visa

Name On Card: Billing Address: Card Number: Expiration Date: CVC Code:

( 3 digits on back)

MasterCard

American Express

SSCC Application

Discover

Stand Sure Credit Counseling Phone: 877-240-1398 Fax: 800-718-4724

Employer #1 Employer #2

Employment Information (From Paycheck or W-2)

Employer #1 Name:

Address: City, State, Zip: Pay Schedule: Gross Monthly Income:

Payroll Deductions

Federal Income Tax: Social Security Tax: Medicare Tax: State Income Tax: Local (City/County) Income Tax: Other Tax:

Other Deductions

Health Insurance: Dental Insurance: Vision Insurance: Health Savings Acct: Disability Insurance: Life Insurance: Long-Term Care Ins.: 401K / Pension: Other:

Employer #2 Name:

Address: City, State, Zip: Pay Schedule: Gross Monthly Income:

Payroll Deductions

Federal Income Tax: Social Security Tax: Medicare Tax: State Income Tax: Local (City/County) Income Tax: Other Tax:

Other Deductions

Health Insurance: Dental Insurance: Vision Insurance: Health Savings Acct: Disability Insurance: Life Insurance: Long-Term Care Ins.: 401K / Pension: Other:

Other Income Other Income

Self-Employment: Alimony/Child Support: Unemployment: Pension/Retirement: Rental Income: Social Security: Disability: Workers' Comp:

*If you have more than two employers, please copy this page to add more information.

SSCC - Form 2

Net Business/Farm Income: Annuity: Interest/Dividends /Royalties: Tips: Commissions: Bonuses: Other Income:

Stand Sure Credit Counseling Phone: 877-240-1398 Fax: 800-718-4724

Housing

Mortgage #1

Monthly Housing & Utility Expenses

Housing Information:

Do you rent or own?

If renting: Monthly Rent: If own: Please complete the mortgage sections below.

Mortgage #2

Description: (ie: Home, Vacation Home, Rental Home, etc.)

Total Mortgage Owed: Monthly Payment: Insurance: Amount in Arrears: # of Payments Behind:

Description: (ie: Home, Vacation Home, Rental Home, etc.)

Total Mortgage Owed: Monthly Payment: Insurance: Amount in Arrears: # of Payments Behind:

Mortgage #4

Description: (ie: Home, Vacation Home, Rental Home, etc.)

Total Mortgage Owed: Monthly Payment: Insurance: Amount in Arrears: # of Payments Behind:

Description: (ie: Home, Vacation Home, Rental Home, etc.)

Total Mortgage Owed: Monthly Payment: Insurance: Amount in Arrears: # of Payments Behind:

Mortgage #3

Monthly Expenses

Electricity: Natural Gas/ Propane: Heating Oil: Water/Sewer: Telephone: Mobile Phone:

SSCC - Form 3A

Monthly Expenses

Cable TV/Satellite: Internet Access: Garbage/Recycling: Homeowner's/ Condo Dues: Real Estate Taxes:

(Not Included Above)

Stand Sure Credit Counseling Phone: 877-240-1398 Fax: 800-718-4724

Living Expenses Living Expenses

Food/Groceries/ Dining Out: School Lunches/ Misc: Household Supplies: Laundry/Cleaning:

Personal Care/ Gromming: Clothing:

Medical Expenses:

Dental Expenses:

Prescriptions:

Gasoline:

Auto Maintenance:

Other Transportation: Licenses/Taxes:

Auto Insurance:

Alimony:

Other Dependent Support: Student Loans:

Judgements:

Monthly Living Expenses

Other Court Collections: Medical Insurance: Life Insurance: Renter's Insurance: Other Insurance: Entertainment: Pet Expenses: Newspapers/ Magazines/ Subscriptions: Alcohol/Tobacco: Child Care: Children's Activities: Children's Items: School Tuition: School Transportation: School Materials: Charitable Donations: Savings: Vacations: Other: Other (Please Describe):

SSCC - Form 3B

Stand Sure Credit Counseling Phone: 877-240-1398 Fax: 800-718-4724

Liabilities & Debts (Taxes Owed/Credit Cards)

Federal Back Taxes: State Back Taxes: County/Local Back Taxes: Property Taxes Owed:

Total Owed

Monthly Payment Amount

Taxes Owed

Credit Card #2

Credit Card #1

Credit Card #5

Credit Card #3

Creditor/Description:

Total Owed: Monthly Payment: # of Payments Behind:

Creditor/Description:

Total Owed: Monthly Payment: # of Payments Behind:

Creditor/Description:

Total Owed: Monthly Payment: # of Payments Behind:

SSCC - Form 4A

Credit Card #6

Credit Card #4

Creditor/Description:

Total Owed: Monthly Payment: # of Payments Behind:

Creditor/Description:

Total Owed: Monthly Payment: # of Payments Behind:

Creditor/Description:

Total Owed: Monthly Payment: # of Payments Behind:

Stand Sure Credit Counseling Phone: 877-240-1398 Fax: 800-718-4724

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