Bankruptcy

1

Are your debts straining your budget* This field is required.

YesNo

2

Are you behind on your debt?* This field is required.

YESNO

3

Do you expect you are going to fall behind in the next 6 months if you don’t take action (if your response in question 2 is Yes please skip)

YESNO

4

What is your household size* This field is required.How many people do you live with including dependents, significant others, etc

5

What is your estimated household income (before taxes)* This field is required.

$0-$40,000

$40-$60,000

$60,000+

6

What is your estimated total unsecured debt (for example: credit cards, medical, vehicle deficiencies, and personal loans)* This field is required.

7

What is your estimated total unsecured debt (for example: credit cards, medical, vehicle deficiencies, and personal loans)* This field is required.

0-$10,000

$10-$25,000

$25-$50,000

$50,000+

8

Are you behind on a mortgage* This field is required.

YESNO

9

Have you been in Florida for more than 90 days?* This field is required.

YESNO

10

Have you ever filed for bankruptcy in the past?* This field is required.

YESNO

11

How is the debt affecting your life? (provide answers they can choose from)* This field is required.

Stress/trouble sleeping

Concerned I can’t support family members

Concerned I can’t afford basic living expenses

Lawsuit/garnishment

Other

12

What would it mean to you to be debt free?* This field is required.

afford to support myself

afford to support my family

ability to save for retirement or major life purchases

get my credit back

13

Name* This field is required.Enter your details so we can email you your personalised report on how to improve your website...

First Name

Last Name

14

Email* This field is required.

example@example.com

15

Mobile Phone* This field is required.We will SMS your report to this number

16

Old Mobile Phone* This field is required.We will SMS your results to this number

17

Score