Application Information Sheet

DebtFreeAmerica.com

P.O. Box 9228
Virginia Beach, VA 23450
(757) 340-2564
Fax (757) 498-6432
Toll Free (800) 4-0-DEBTS
Toll Free Fax (800) 256-3504

Application Information SheetGENERAL INFORMATION

Name: ___________________	Social Security: #_____ - ___ - ______
Spouse: __________________	Social Security: #_____ - ___ - ______
Address: _____________________________________________________
City: _________________________ State: _______ Zip:___________
Home Telephone: (___)_____ - __________ Work Telephone: (___)____ - _______
Dependents in Household:_________ E-Mail Address: _______________________

MONTHLY BUDGET ANALYSIS

(Required by creditors)

Expenses

Total Net Income

Rent Payment	$________.	Insurance: Life	$________.
Mortgage Payment	$________.	Auto	$________.
Automobile: Payments	$________.	Home	$________.
Gasoline/Oil	$________.	Medical	$________.
Household (grocery)	$________.	Medical Expenses	$________.
Utilities: Gas	$________.	Child Support	$________.
Electric/Cable	$________.	Childcare/Daycare	$________.
Water/Sewage	$________.	Misc./Charities	$________.
Phone/Cellular	$________.
Total Monthly Expense $____________.

Applicant	$________.
Co-Applicant	$________.
Retirement	$________.
Social Security	$________.
Child Support Income	$________.
AFDC	$________.
Food Stamps	$________.
TOTAL	$________.
Less (subtract) Expenses	$________.
Estimated HCCS Min Payment	$________.
Available Balance	$________.

Reason for Debt Management Program: (MUST Check most appropriate)( )Poor management ( )Divorce ( )Death in family ( )Reduced income ( )Medical/Disability ( )Confidential
Balance of Unsecured Debt $____________ Regular Monthly Payments $____________
Balance of ALL Secured Debt $____________ Est. Assets $____________ Est. Liabilities $____________

Instructions:

Complete BOTH this application and the creditor form.

For verification of accuracy, include CURRENT COPIES of most recent creditor statements
Sign the Credit Management Agreement,
SPECIAL NOTE: You may need to change the due dates and cancel credit card insurance to avoid increases in fees and finance charges. Your account advisor will assist you in selecting the most appropriate payment date.
Enclose your estimated Total Monthly Payment Amount, and return all of the above information either by mail or fax.
If FAXING these documents, you must immediately follow with a check or money order for the estimated HCCS amount. Print your name and social security number clearly with your payment. Please note that checks require a 10 day holding period before dispersing.
Remember, in a debt management plan you are required to close all existing accounts (except those needed for business purposes).
You must avoid additional debt.

Payment Information:

Your initial payment is to be made by either check or Money Order payable to HCCS TRUST. Your name and social security number must be clearly printed. Processing for your Debt Payment Plan application can not begin until your Estimated Total Monthly payment is received.

(THIS FORM IS PART OF THE DEBT MANAGEMENT AGREEMENT)