FILING STATUS:
Single ($50)
Married ($60 total)

ARE YOU CURRENTLY EMPLOYED?
Yes
No

YOUR EMPLOYER:  


WHAT IS TOTAL MONTHLY HOUSEHOLD INCOME BEFORE TAXES?  

HOW MANY CREDIT CARD [AND STORE CARD] ACCOUNTS DO YOU CURRENTLY HAVE OPEN? 
HOW MANY CREDIT CARDS (WITH BALANCES) DO YOU CARRY? 

TOTAL CREDIT CARD BALANCE: 

TOTAL CAR LOAN BALANCE(S): 

TOTAL 'OTHER' LOAN BALANCE:    Specify other type 
OTHER LOANS = (doctor bills, home equity, consolidation, & other loans)

TOTAL DEBT:
TOTAL DEBT = (student loans, credit cards, car,& all other loans except home mortgage)

CHECK ALL OBLIGATIONS WHICH ARE CURRENTLY OVERDUE:
Utilities
Telephone
Child/Spouse support
Credit card or other loans
Rent/Mortgage payment
Car payment
Other (specify) 

NONE OF THE ABOVE ARE OVERDUE

DO YOU HAVE ANY INVESTMENTS:

YES    NO

IF YES, HOW MUCH?