Debt Consolidation Qualification Questionnaire
Please complete this form in full to determine if you qualify for debt consolidation. All information will remain confidential.
Personal Information
Name
*
First Name
Last Name
Date of Birth:
*
-
Month
-
Day
Year
Date
Social Security Number (Last 4 Digits):
*
Phone Number:
*
Email Address:
*
City:
*
State:
*
ZIP Code:
*
Employment & Income Information
Employment Status (Check One):
*
Employed (Full-Time)
Employed (Part-Time)
Self-Employed
Unemployed
Retired
Student
Employer Name (If applicable):
Job Title:
*
Monthly Gross Income (Before Taxes): $
*
Other Income Sources (Child Support, Social Security, etc.): $
*
Debt Information
Please list all debts, including credit cards, loans, medical bills, and any other outstanding obligations.
Rows
Creditor Name
Type of Debt
Balance Owed
Minimum Monthly Payment
Interest Rate (%)
Account Status (Current/Past Due)
Friendliness
Total Debt Balance:
*
Total Monthly Debt Payments:
*
Assets & Expenses
Do you own a home?
*
Yes
No
If Yes:
Rows
$
Current Home Value:
Mortgage Balance:
Monthly Mortgage Payment:
Do you have a second mortgage or HELOC?
Yes
No
Other Assets (Vehicles, Savings, Investments, etc.):
Rows
-
Vehicle(s) Owned:
Savings Account Balance: $
Investment Account Balance: $
Monthly Expenses (Estimate):
Rows
$
Rent/Mortgage Payment:
Utilities (Electric, Water, Gas, etc.):
Insurance (Car, Health, Life, etc.):
Food & Groceries:
Transportation (Gas, Public Transit, etc.):
Other Necessary Expenses:
Financial History & Credit Information
Credit Score (If Known):
Have you ever filed for bankruptcy?
Yes
No
If Yes, when?
Have you had any accounts sent to collections?
Yes
No
Have you had any late or missed payments in the past 12 months?
Yes
No
Debt Consolidation Goals
1. What are you hoping to achieve with debt consolidation? (Check all that apply)
*
Lower monthly payments
Reduce interest rates
Pay off debt faster
Simplify payments into one monthly bill
Improve credit score
Avoid bankruptcy
Are you open to working with a financial advisor to create a personalized debt relief plan?
*
Yes
No
Additional Comments or Concerns:
*
Authorization & Signature
I certify that the information provided above is accurate and complete to the best of my knowledge. I authorize a financial professional to review my information and contact me regarding debt consolidation options.
Signature:
*
Date
*
-
Month
-
Day
Year
Date
This form provides a thorough assessment of an individual’s financial situation, ensuring an accurate review for potential debt consolidation solutions. Let me know if you need any further modifications!
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