Credit Restoration Consultation Form
INTAKE FORM
Section 1: Personal Information
Name
First Name
Last Name
Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
Email
example@example.com
Section 2: Credit Information
Which of the following do you need assistance with?
Late Payments
Collections
Lien
Bankruptcy
Repossession
Judgement
Multiple Accounts
Other
If you have late payments, were you actually late?
Yes
No
Are debt collectors contacting you by mail, email, text or call?
Yes
No
How are the debt collector contacting you? Who is the company contacting you?
Is the debt collector harassing you or using language to try to force you to pay?
Are there personal information, accounts or inquiries on your credit report that does not belong to you?
Yes
No
I’m unsure
Do you have accounts on your credit report that you’ve paid but it shows not paid?
Yes
No
Other
Are you having trouble qualifying for an extension of credit due to an account? If so which are you being denied for?
Auto Loans
Jobs
Mortgages
Loans
Credit Cards
Apartment/Condo
I haven’t applied for credit
Other
Have you ever had credit repair done before, including disputing on your own?
Yes
No
Other
If so, what company completed credit repair and when was it done?
Are you in a rush to get your credit restored?
Yes, I need results immediately
No
What is your main reason for wanting to restore your credit and what is your time frame expectation?
Are you being garnished on an account on your credit report?
Yes
No
Other
If you are being garnished on an account that’s on your credit report please list the account below?
In order to review your credit reports, we need access to your login credentials via Experian, Equifax and Transunion. (Creating a login is free) Do you understand we cannot complete a thorough review without all 3 logins?
Yes, I understand
No
If you cannot ontain your logins, upload your 3 most recent full credit reports from Annual Credit Report.
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What specific updates or changes would you like to see reflected on your credit report from Zee Blessed Ent?
Section 3: Commitment to The Process
Are you committed to avoiding new negative accounts or inquiries during the restoration process?
Yes
No
Are you comfortable uploading or emailing documentation like ID, utility bills, and letters?
Yes
No
Do you agree to respond to communication within 48 hours?
Yes
No
Would you be interested in resources in financial literacy resources to help you better understand credit. budgeting, and money management?
Yes
No
Section 4: Employment Information
Are you currently employed?
Yes
No
Additional Notes
DISCLAIMER SECTION
I understand that the purpose of this form is to provide preliminary information for a credit consultation and review. Submitting this intake form does not guarentee enrollment into our credit restoration program. This is not a binding agreement for services. I acknowledge that:
This is an initial consultation tool used to determine if i qualify for credit restoration services.
No services will be rendered until a formal service agreement is reviewed and signed.
Any advice of feedback provided during the consultation does not constitute legal, financial, or tax advice.
I understand individuals credit outcomes vary based on participation and circumstances.
I certify that the information I`ve provided is accurate to the best of my knowledge.
Signature
Date
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Month
-
Day
Year
Date
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