Debt Help USA - Prequalification Form

Fill out the pre-qualification worksheet below and
click the submit button

This is just preliminary information to see if you qualify you for a debt settlement or debt management program.
It does not obligate you in any way. One of our representatives will contact you to review your options.

Name:
E mail:
Phone:

List the unsecured creditors with debt amounts of that you would like to enroll:

creditor name	amount owed	monthly payment	interest rate
creditor name	amount owed	monthly payment	interest rate
creditor name	amount owed	monthly payment	interest rate
creditor name	amount owed	monthly payment	interest rate
creditor name	amount owed	monthly payment	interest rate
creditor name	amount owed	monthly payment	interest rate
creditor name	amount owed	monthly payment	interest rate
creditor name	amount owed	monthly payment	interest rate
creditor name	amount owed	monthly payment	interest rate
creditor name	amount owed	monthly payment	interest rate
creditor name	amount owed	monthly payment	interest rate
creditor name	amount owed	monthly payment	interest rate
creditor name	amount owed	monthly payment	interest rate
creditor name	amount owed	monthly payment	interest rate
creditor name	amount owed	monthly payment	interest rate

Are you behind in paying

some or all of these creditors?

YES

How many months behind?

Comments:

(If you have more than fifteen creditors complete this form and click submit and then hit refresh and enter the additional creditors on a second form just including your name above)

Monthly Net Income/Expense Overview:

APPLICANT - Monthly NET Income: (less taxes and deductions)
CO- APPLICANT - Monthly NET Income: (less taxes and deductions)
Other Income:
Total Monthly NET Income:

NECESSARY MONTHLY EXPENSES: (do not include credit card payments)
Rent or Mortgage Payments:
Auto (lease or purchase payments)
Utilities:
Gasoline:
Education:
Phone
Food and Groceries:
Insurance:
Medical:
Misc:

(Please only click the submit button one time, it will take a few seconds to process)

Fill out the pre-qualification worksheet below and click the submit button

Fill out the pre-qualification worksheet below and
click the submit button