Financial Independence Application

Financial Independence Program

Fill the form below accurately indicating your potential and suitability for The Financial Independence Program.
Section 1: Personal Information
Name*

First NameLast Name
Birth Date

MonthDayYear
Phone Number*
Format: (000) 000-0000.
Email
example@example.com
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Section 2: Financial Status
Total Monthly Income:
YesNo
If yes, which programs? (SNAP, TANF, Housing Assistance, etc.)
YesNo
If yes, where do you work?:
Current Credit Score (if known):
Total Debt Amount (if known):
Section 3: Financial Goals & Readiness
What Are Your Top 3 Financial Goals?
Have You Ever Created A Budget Before?
YesNo
YesNo
Are You In Need Of Assistance Paying For FIP?
Company WebsiteReferralFacebookTwitterLinkedInOther (please specify)
Should be Empty:

Section 1: Personal Information