Credit Repair Client Intake Form

Credit Repair Intake

Please provide all required details to enroll into our credit repair program. Try to provide the information connected to your current credit accounts.
Full Legal Name (as shown on credit):

First NameMiddle NameLast Name
DOB:
Last 4 of SSN:
E-mail
example@example.com
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Current Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Previous Address (if moved in last 2 years):

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Have you ever disputed any accounts before?
Credit Repair Services
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Full Credit Repair
This option is best for clients who want to get started immediately and save overall. With the pay-in-full option, you receive full access to my credit repair services with no monthly payments or ongoing charges.Includes:• Credit report analysis• Personalized dispute strategy• Disputing inaccurate, outdated, or unverifiable items• Ongoing updates throughout the program• Credit education to help improve and maintain your score✔ One-time payment✔ No monthly fees✔ Best value option

$600.00 Color

5-15 Disputes
This option is ideal for clients who prefer flexibility. The monthly payment plan allows you to receive the same credit repair services while spreading the cost over time. Includes: • Credit report analysis • Personalized dispute strategy • Disputing inaccurate, outdated, or unverifiable items • Ongoing updates throughout the program • Credit education to help improve and maintain your score ✔ Lower upfront cost ✔ Flexible monthly payments ✔ Auto-pay enrollment required

$125.00 How Many Disputes
Payment Type
Should be Empty:

Credit Repair Intake

Credit Repair Services *

Credit Repair Services