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| Last Name: |
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| Address: |
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| State |
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| Daytime Phone: |
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| Email Address: |
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| Are you currently employed? |
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| Are you receiving unemployment? |
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| Are you in danger of losing your home? |
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| Is your house payment difficult to make? |
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| Are your car payment(s) difficult to make? |
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| Do you have unsecured debt (credit cards)? |
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| Are your credit card payments difficult to make? |
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| Are you considering Bankruptcy? |
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| Have you filed Bankruptcy before? |
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| If so, when? |
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| Chapter 7 Bankruptcy or Chapter 13 Bankruptcy? |
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| Have you talked to a financial counselor before? |
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| Do you need to build new credit? |
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| Do you have errors on your credit report driving your score down? |
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| Do you want to eliminate your credit card and other debt?: |
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| Are you trying to save your home and avoid foreclosure? |
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| Do you need Bankruptcy or other Counseling services? |
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| Other: |
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| Were you referred to us? or How did you hear about us? Please let us know! |
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