Debt Elimination Basic Client Information
This Information is Private, SECURE, and Confidential Between Client and Specialist
Client Name
*
First Name
Last Name
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Date of Birth
*
-
Month
-
Day
Year
Date
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Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
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Phone Number
*
Please enter a valid phone number.
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Email Address
*
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Tobacco User
*
Yes
No
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Health Issues (Descriptions)
*
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What Debts Do You Currently Have That You Want Eliminated? (Click all that Apply)
*
Mortgage
Home Equity Loan
Auto Loan(s)
Student Loan
Medical Debt
Tax Debt
Other
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Mortgage Total Balance and Monthly Payment
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Do you pay any extra money monthly towards any of the debts above?
*
If so, how much and to which debts
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Monthly Income?
*
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Do you contribute to any retirement plans or savings monthly?
*
If so, how much?
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Would you like to learn how to become "Your Own Bank?"
*
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Best Time to Call or Text?
*
If my application is approved, I understand that a Specialist from the Debt Elimination Team will contact you to book an initial appointment.
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Referring Person's Name (Who directed this to you?)
*
First Name
Last Name
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Submit
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