Community Credit Counseling Specialists 

5301 Southwyck Blvd., Suite 100  - Toledo, Ohio 43614-1580 - 419-865-2333 - Fax 419-868-0207 
Toll Free - 1-888-662-3313
 

Debt Repayment Program Application
Financial Information

Note: Use this application when applying for Debt Repayment Program (DRP) assistance from Community Credit Counseling Specialists. If you are applying for our Bankruptcy Assistance Program please use the Bankruptcy Application (click here)
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To enable us to expedite the counseling and verification process - fill out this counseling application and send it to us by clicking the Submit button at the bottom of this form or print the completed form and fax it back to us at  419-868-0207 (fax) or call us for assistance.

Please complete as much of the following information as possible:

Name:

 *Required
Spouse's Name:
Street Address: *Required
Address (cont.):
City: *Required
State: *Required
Zip: *Required
County: *Required
Work Phone:
Home Phone: *Required
E-mail: *Required
Reason For Inquiry: *Required


Please check this box to confirm*

*Required
 
 I have read and understand the information in Form A18-DRP Client Disclosure Information  located in the Forms section of this website. I understand that any questions which I might have in regard to information contained in Form A-18-Disclosure Information to Clients will be answered to my satisfaction before agreeing to utilize the counseling services provided to me by Community Credit Counseling Services.

Budget Worksheet

To allow us to serve you better, please complete as much of the information as possible.

Income

What is your monthly take home pay after deductions?

What is your Spouse's monthly take home pay after deductions?

What monthly income do you have from a military retirement, retirement or pension?

What monthly income do you receive from child support?

What monthly income do you receive from social security?

What monthly income do you receive from government benefits, i.e.: food stamps etc.? 

What monthly income do you receive from investments, CD's, rentals et.?

Your Total Monthly NET Income:

Expenses
What is your monthly rent?
What is your monthly mortgage payment?
What is your monthly 2nd. mortgage or equity line payment?  
What are your total average monthly utilities  (gas, electric, phone, cell etc.)?
What is your total monthly average amount spent on groceries and dining out?
What are your total monthly automobile payments?
What are your total monthly average automobile expenses (gas, repairs etc.)? 
What are your total monthly insurance payments (life, auto, medical, dental)?
What are your total average monthly medical expenses?
What do you pay in monthly child support?
What do you pay in monthly day care?
All other monthly expenses (gifts, laundry, newspaper, clothing, entertainment, etc.?
Other installment loan monthly payments (excluding unsecured debts listed below)?
Total monthly expenses:
     
Total number of Dependents:  
What is the reason for your hardship?

List of Creditors
Creditor 1 Name

Debt Type
Monthly Payment $

Interest Rate

 %
Months Delinquent  

Amount Delinquent

 $
Current Balance $

Primary Name
On Account:

___________________________________________________________________________________

Creditor 2 Name

Debt Type
Monthly Payment $

Interest Rate

 %
Months Delinquent  

Amount Delinquent

 $
Current Balance $

Primary Name
On Account:

___________________________________________________________________________________

Creditor 3 Name

Debt Type
Monthly Payment $

Interest Rate

 %
Months Delinquent  

Amount Delinquent

 $
Current Balance $

Primary Name
On Account:

___________________________________________________________________________________

Creditor 4 Name

Debt Type
Monthly Payment $

Interest Rate

 %
Months Delinquent  

Amount Delinquent

 $
Current Balance $

Primary Name
On Account:

___________________________________________________________________________________

Creditor 5 Name

Debt Type
Monthly Payment $

Interest Rate

 %
Months Delinquent  

Amount Delinquent

 $
Current Balance $

Primary Name
On Account:

___________________________________________________________________________________

Creditor 6 Name

Debt Type
Monthly Payment $

Interest Rate

 %
Months Delinquent  

Amount Delinquent

 $
Current Balance $

Primary Name
On Account:

___________________________________________________________________________________

Creditor 7 Name

Debt Type
Monthly Payment $

Interest Rate

 %
Months Delinquent  

Amount Delinquent

 $
Current Balance $

Primary Name
On Account:

___________________________________________________________________________________

Creditor 8 Name

Debt Type
Monthly Payment $

Interest Rate

 %
Months Delinquent  

Amount Delinquent

 $
Current Balance $

Primary Name
On Account:

___________________________________________________________________________________

Creditor 9 Name

Debt Type
Monthly Payment

Interest Rate

 %
Months Delinquent

Amount Delinquent
Current Balance

Primary Name
On Account:

___________________________________________________________________________________

Creditor 10 Name

Debt Type
Monthly Payment

Interest Rate

 %
Months Delinquent

Amount Delinquent
Current Balance

Primary Name
On Account:

___________________________________________________________________________________

Creditor 11 Name

Debt Type
Monthly Payment

Interest Rate

 %
Months Delinquent

Amount Delinquent
Current Balance

Primary Name
On Account:

___________________________________________________________________________________

Creditor 12 Name

Debt Type
Monthly Payment

Interest Rate

 %
Months Delinquent

Amount Delinquent
Current Balance

Primary Name
On Account:
Note: 
If you need to list additional creditors, submit this form and return to the form entering your name and the additional creditors.
 
PLEASE PRINT A COPY ON YOUR PRINTER BEFORE CLICKING "SUBMIT FORM"

Community Credit Counseling Specialists, Inc.
Copyright © 2001, 2003, 2006, 2008 Community Credit Counseling Specialists, Inc.. All rights reserved.
Revised: November 06, 2009