General Information Worksheet

Consumer Credit Counseling Service - 2021 Cunningham Drive, Suite 400, Hampton, VA 23666  (757) 826-2227  - version updated 7/15/2015

Please complete the following form so that we can assist you.

* - indicates required fields so we can contact you in case we have questions

Applicant Information

   *Last Name:     Middle / Maiden Name:     *First Name  
   Date of Birth: (Format:  00/00/0000)   Last 4 Digits of Social Security Number:

   Address: 

   City:     State:    Zip Code:

   *E-mail Address:     *Best phone # to contact you:

  How did you learn about us?
  Referral from Other Than Listed
 

   Marital Status: 
   Pay Frequency:      Take Home Pay Before Taxes:      Monthly Take Home Pay After Taxes:  
   Employer:     Phone:    How Long:   Years: Months:   Position:
   Deduction Total From Each Pay Period For Loans, Savings, etc:     Other Income: 
   Dependents:     Number:     Ages:   (list ages and separate with a comma)
   Housing Status:      Is Rent/Mortgage Delinquent?
Spouse Information Leave blank if unmarried and proceed to Creditor Information Below

   Last Name:     Middle / Maiden Name:     First Name  
   Date of Birth: (Format:  00/00/0000)   Last 4 Digits of Social Security Number:

   Address: 

   City:     State:    Zip Code:

   E-mail Address:     Best phone # to contact you:

   Pay Frequency:      Monthly Take Home Pay:  
   Employer:     Phone:    How Long:   Years: Months:   Position:
   Deduction Total From Each Pay Period For Loans, Savings, etc:     Other Income: 
   Dependents:     Number:     Ages:   (list ages and separate with a comma)
   Housing Status:      Is Rent/Mortgage Delinquent?
Creditor Information 

Creditor Account Number Balance Monthly Payment Interest Rate Months Delinquent
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
Asset  Information

    Asset 1:    Current Retail Value: 
    Asset 2:    Current Retail Value: 
    Asset 3:    Current Retail Value: 
    Asset 4:    Current Retail Value: 
    Asset 5:    Current Retail Value: 
    Asset 6:    Current Retail Value: 
    Asset 7:    Current Retail Value: 
    Asset 8:    Current Retail Value: 
    Asset 9:    Current Retail Value: 
  Asset 10:    Current Retail Value: 
Monthly Living Expenses 

Rent/Mortgage Health Insurance Baby Sitter
 Second Mortgage Car Maintenance Dental/Optical
Renter/Homeowner  Groceries Medication
Insurance Meals Out Church/Charities
Car Payment #1 School lunches Postage
Car Payment #2 Electricity Personal Care
Child Care Oil, Gas Pet Care
Tax Installments Water/Sewage/Garbage Home Security, Lawn/Pool
Child Support Telephone/Mobile/Pager Maintenance
Savings Clothing Cable/TV
Property Taxes Dry Cleaning/Laundry Vacation/Travel
Life Insurance Cleaning Supplies Barber/Beauty Shop
Auto Insurance Gasoline Books/Newspaper/Magazines
Auto Tags/ Inspections Bus Fares/Parking Movies/Sports/Entertainment
Car Taxes Diapers, Formula School Tuition/Supplies