Concord Credit Secure Intake Form

Concord Credit — Secure Client

Your information is encrypted. Sensitive items are never sent by email. Questions? Call 217-486-1757 or email admin@concord.credit
Section A — Applicant Information

Tell us who you are so we can create your secure file.
Full legal name*

First NameLast Name
Personal Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Mobile phone*
Help text: We’ll text important status updates and appointment reminders.
Date of Birth*

MonthDayYear
Social Security number*
Used once for identity verification and to access your credit data securely.
Section B — Your Goals & Budget

Help us tailor the fastest, most cost-effective path.
Have you signed up for credit monitoring?*
Required to begin work
Housing Status*
Monthly housing payment*
Budget for credit improvement*
This figure is vital. It tells us how aggressive we can be in sequencing disputes and utilization reductions for the quickest score gain.
Government-issued ID (Driver’s License or Passport)*

Upload front and back if applicable. Accepts JPG/PNG/PDF. Max 10 MB.
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Social Security Card*

Upload a clear image of the front (and back if applicable).
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Proof of Address(Water/Electrical Bill)*

Dated within the last 60 days. Your name and address must be visible.
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Sign & Submit*

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Concord Credit — Secure Client