Language
English (US)
Debt Free 4 Life Basic Client Information
This Information is Private, SECURE, and Confidential Between Client and Specialist
Client Name
*
First Name
Last Name
Date of Birth
*
-
Month
-
Day
Year
Date
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Phone Number
*
Please enter a valid phone number.
Email Address
*
Tobacco User
*
Yes
No
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Health Issues (Descriptions of any Diagnosis)
*
Are you taking any prescriptions? If so, what? Dose? If none, put N/A
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Debt Totals and Interest Rates
These are the debts you want eliminated. Fill out all that apply.
Mortgage Balance and Interest Rate
Auto Loan Balance and Interest Rate
Auto Loan Balance and Interest Rate
Auto Loan Balance and Interest Rate
Student Loan Balance and Interest Rate
Misc Loan Balance and Interest Rate
Example: Home Improvement Loan, Etc
Misc Loan Balance and Interest Rate
Example: Boat, Home Equity, Consolidation Loan
Credit Card Balances and Interest Rates
List All That Need To Be Paid Off
Tax Debt?
Federal or State Tax Debt (Include Payment Plans
Medical Debt
Balances of Medical Debt
Referring Agent Name
*
First Name
Last Name
Submit
Should be Empty: