APPLY ONLINE - New Client Online Application

PRIMARY DEBTOR:

First Name:

SECONDARY DEBTOR:

First Name:

Last Name:

Last Name:

Date of Birth:  

Date of Birth:  

Street Address:

Street Address:

City:  

City:  

State:  

State:  

Zip:  

Zip:  

Home Phone:  

Home Phone:  

Cell Phone:  

Cell Phone:  

Email (required):  

Email:  

Relationship of Primary Debtor to Secondary Debtor

BANK INFORMATION

List the banks and credit unions where you have accounts. (checking, savings, cds, etc)
Do not write in account numbers.

#1.  

#2.  

#3.  

#4.  

Are you banking at an institution to which you owe money and are intending to provide to DCSD for representation?  

Do you have a job?:  

Employer:  

Hours worked per week:  

Hourly Rate:  

Do you have any Certificates of Deposit?  

401K?  

IRA?  

Stocks?  

Bonds?  

Mutual Funds?  

REAL PROPERTY INFORMATION

Do you own a home?  

Current value of home?  

How much is owed on all mortgages?

Is there another name on the title to this property?

Is your name on any other real estate?

Do you have any time share properties?

PERSONAL PROPERTY INFORMATION

Do you own any assets such as expensive jewelry, expensive artwork, Gun collection, coin or stamp collections, etc?  

VEHICLE INFORMATION

List any recreational vehicles you have. (ie., motor homes, ATV, etc.)

#1.  

#2.  

CREDITOR INFORMATION

Approximately How many debts would you like us to handle for you?

Unsecured Loans

Signature Loans:  

Line of Credit:  

Deficiencies (foreclosure/repossession)

Mortgage:  

Vehicle Loan:  

COMMENTS: