APPLICATION

Consumer Credit Counseling Service of Rochester works with both clients and creditors to design a debt repayment program that minimizes monthly debt payments and interest associated with the debt. We create manageable, custom debt consolidation and repayment plans for each of our valued clients.

The information you submit in the following application will help our certified debt counselors evaluate your situation and be prepared to discuss a debt consolidation and repayment plan with you. After filling out and submitting this online application, a certified debt counselor will call or e-mail you to set up an appointment discuss your debt repayment options.

All information submitted in this application will only be used for the debt repayment services we provide. Consumer Credit Counseling Service of Rochester uses state-of-the-art security, to ensure your privacy. The information you enter in this application will remain confidential.

Applicant's Information	Spouse's Information
Last Name:	Last Name:
First Name:	First Name:
MI:    DOB (mm/dd/yy):	MI:    DOB (mm/dd/yy):
Social Security Number:	Social Security Number:
Phone:	Phone:
Email:	Email:
Password:
Confirm Password:
Employer Information
Employer:	Employer:
Address:	Address:
Phone:	Phone:
Length of Employment:	Length of Employment:
Job Title:	Job Title:

Pay Per Week
Gross $	Net $	Gross $	Net $
Non-standard deductions taken from your pay
Type/By Whom		Type/By Whom
Amount $		Amount $
How Often?		How Often?
Wages Garnisheed?
YESNO      Amount $		YESNO      Amount $
By Type/By Whom?		By Type/By Whom?
Any Additional Income?
YESNO      Amount $		YESNO      Amount $
Last grade completed?   1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20		Last grade completed?   1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20

Address Info
Street:	City:
	How long at address?
Own  Rent Mortgage Holder/Landlord: Mo Pmt $ For Mortgage: Current Balance $ Value $
Previous Address:	How long there?:
Are you: SingleMarriedSeparatedWidowedDivorced    Number of dependent children:     Ages:
Car(s):
Year   Where Financed Make Monthly Payment
Year   Where Financed Make Monthly Payment
Have you ever filed for bankruptcy?
YESNO When Amount $ Where did you hear about our services?

MONTHLY LIVING EXPENSES
NET FAMILY INCOME
EXPENSE ITEMS		WEEKLY	MONTHLY
Rent/Mortgage/Lot Rent/2nd Mortgage
Property Tax
Property/Renters Insurance
Heat/Electric/Propane/Wood/Oil
Phone: Local/Long Distance/Cellular/WWW
Water/Sewer/Septic/Garbage
Cable/Satellite/Video Rental
Groceries
Lunches Away - At School
Life Insurance
Hospital/Medical Insurance
Auto Loans
Auto Insurance
Gasoline/Bus Fare/Parking
Auto Repairs
Tuition
Books/Magazines/Newspapers
Clothing
Laundry/Dry Cleaning
Doctor/Dentist (copay)
Drugs/Medication
Cigarettes/Beer/Liquor
Entertainment
Gifts: Birthdays/Christmas
Church/Charities
Child Care
Alimony/Child Support
Student Loans
Personal Loans
Miscellaneous 1
Miscellaneous 2
Miscellaneous 3
Please press calculate
TOTAL LIVING EXPENSES
This is what you have left FOR DEBT REPAYMENT

LIST ALL CREDITORS
(If you have more than one account for one creditor, list each account separately.)
:::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::: Account 1 ::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::
Creditor Name  Account Number Acct Type	Street or PO Box  City                   State     Zip              Phone No.	Current Bal $     Monthly Pmt $     Collateral $	Date Last Pd When Opened
:::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::: Account 2 ::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::
Creditor Name  Account Number Acct Type	Street or PO Box  City                   State     Zip              Phone No.	Current Bal $     Monthly Pmt $     Collateral $	Date Last Pd When Opened
:::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::: Account 3 ::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::
Creditor Name  Account Number Acct Type	Street or PO Box  City                   State     Zip              Phone No.	Current Bal $     Monthly Pmt $     Collateral $	Date Last Pd When Opened
:::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::: Account 4 ::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::
Creditor Name  Account Number Acct Type	Street or PO Box  City                   State     Zip              Phone No.	Current Bal $     Monthly Pmt $     Collateral $	Date Last Pd When Opened
:::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::: Account 5 ::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::
Creditor Name  Account Number Acct Type	Street or PO Box  City                   State     Zip              Phone No.	Current Bal $     Monthly Pmt $     Collateral $	Date Last Pd When Opened
:::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::: Account 6 ::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::
Creditor Name  Account Number Acct Type	Street or PO Box  City                   State     Zip              Phone No.	Current Bal $     Monthly Pmt $     Collateral $	Date Last Pd When Opened
:::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::: Account 7 ::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::
Creditor Name  Account Number Acct Type	Street or PO Box  City                   State     Zip              Phone No.	Current Bal $     Monthly Pmt $     Collateral $	Date Last Pd When Opened
:::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::: TOTAL DEBT :::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::: Total Debt      Total Monthly Payment
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