Credit Card Debt Assessment

Contact Information
First Name		Last Name
Middle Initial		Age
Sex	Select Male Female No Answer	Marital Status	Select Single Married Divorced Domestic Partnership
Street Address 1		Street Address 2
City		State
Zip Code
Home Phone		Alternate Phone
E-Mail Address

Credit Card Balances
What is the approximate amount of your credit card debt?	Select Under $5,000 $5,000 - $10,000 $10,000 - $15,000 $15,000 - $20,000 $20,000 - $25,000 Over $25,000
Are you the person solely responsible for payment?	Select I am solely responsible Myself & my spouse are responsible I am a co-signer I have a co-signer who is not related I have a co-signer who is related
Have you been sued by a credit card issuer?	Select Yes No
Are you being contacted by bill collectors?	Select Yes No
How many credit cards do you have with a balance over $100?	Select 1-3 4-7 8-10 More than 10
How many credit cards with a balance over $100 are past due?	Select All past due 1-3 past due 4-7 past due 8-10 past due None past due

List the top 10 credit cards that are past due:

Issuing Bank	Balance	Amount past due	# of months past due	Interest Rate

General Information

Employment Status	Select Un-employed Retired Disability Income Self-employed Employed-1099 Employed-W2
Do you own or rent your home?	Select Own Rent
Have you experienced any of the following in the last 12 months? (check all that apply)	Illness Loss of job Family Death Divorce Substance Abuse
	Other

Do you have any other special circumstances we should know about?

Payment Information

Billing Information
Name (As it appears on credit card) *
Type of card *	Visa Master Card Discover
Card Number *
Expiration Date *
Security Code *