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Income and Expense Details
Finances and Expenses
Client Information
First Name
*
Last Name
*
Phone
*
Email
*
Client ID
Monthly Income
Please be as accurate as possible - This information helps during the negotiation process.
Take Home Pay
$
Pension/Retirement
$
Social Security
$
Alimony/Child Support
$
Other Income
$
Total Monthly Income
$
Monthly Expenses
Do You Rent or Own?
Rent
Own
Mortgage Amount (First)
$
Mortgage Amount (Second)
$
Property Taxes
$
Monthly Rent
$
Renters Insurance
$
Cable/Subscriptions (Netflix, Hulu, Disney, etc.)
$
Cell Phone
$
Bundle (cable/phone/internet)
$
Electricity
$
Gas (Heating)
$
Water
$
Groceries
$
Entertainment
$
Car Insurance
$
Gas
$
Car Payment 1
$
Car Payment 2
$
Health Insurance
$
Other Monthly Medical Expenses
$
Child Care
$
Child Support
$
Miscellaneous
$
Total Monthly Expenses
$
Bank/Financial Accounts
Current Open Accounts - We will need to know the name of the institution and account balance for each.
Savings Account
Checking Account
401K/403B Balance
Savings Account Information
Name of Bank
Current Balance
Checking Account Information
Name of Bank
Current Balance
Retirement Account Information
Type of Account
Current Balance
Total of Account Balances
$
Hardship Information
This information is needed in the event one or more of your accounts is facing legal action.
Marital Status
Married
Single
Engaged
Divorced
Separated
Widowed
Number of Children Under 18 Years Old
Number of Other Dependents
Do you file as Head of Household when filing taxes?
Yes
No
Do you owe back State or Federal taxes?
Yes
No
Amount of back taxes owed
Have you ever previously filed bankruptcy?
Yes
No
What year did you file bankruptcy?
If you are human, leave this field blank.
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Debt Relief
Our Program
Testimonials
Finance Blog
Contact
Contact Us
File a Complaint
AFCC Disclosure
Free Debt Consultation
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