Today's Date
-
Month
-
Day
Year
Date
First Name
*
Last Name
*
E-mail
*
example@example.com
Date of Birth
*
/
Month
/
Day
Year
Date
Address
*
Street Address
Suite/Apt
Street Address Line 2
City
*
City
State/Province
*
State/Province
Postal/Zip Code
*
State/Province
Home Phone
-
Area Code
Phone Number
Cell Phone
*
-
Area Code
Phone Number
Marital Status
*
Single
Married
Divorced
Widowed
Do you need a consumer loan?
*
Yes
No
Employment Status
*
Retired
Self Employed
Unemployed
Receiving other income
Business Owner
Starting a Business
Employed
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Do you have a Checking Account?
*
Yes
No
Do you have a Realtor?
*
Yes
No
Do you have a Lender?
*
Yes
No
Are your bills current?
*
Yes
No
Have you been denied credit recently?
*
Yes
No
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Current Credit Challenges
Do you have a recent copy of your credit report?
Yes
No
Late payments
*
Yes
No
Collections
*
Yes
No
Charge Offs
*
Yes
No
Judgements
*
Yes
No
Foreclosure
*
Yes
No
Repossessions
*
Yes
No
Short Sale
Yes
No
Eviction
*
Yes
No
Medical Bills
*
Yes
No
Child Support
*
Yes
No
Inquiries
Yes
No
Tax Liens
*
Yes
No
Bankruptcy
Yes
No
If Yes, What type
Chapter 7
Chapter 13
Both
Short Sale
*
Yes
No
Student Loans
*
Yes
No
If you have existing student loans, what is the current status?
Current
Defaulted
Deferred
Repayment plan
Do you have any open credit cards?
*
Yes
No
If so, how many
ex: 5
Open Revolving Accounts (Credit cards)
*
Ex: Master Card, Visa, Fingerhut, Walmart, Sams etc
What type of services are you interested in (check all that apply)?
*
Consumer Loan
Credit and Budget Counseling
Credit Counseling
Business Consulting
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Please share your story and goals:
*
Any additional comments:
Do you have a legal advisor?
*
How did you learn about HOPE?
*
Candys Tax Service Credit Docs
Lender
Realtor
Google
Yahoo
Bing
Yellow Pages
Flier
Friend
Other
If you were referred, please provide the name of the person/organization that referred you:
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