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To determine if Credit Counselors Corp. will be best for you, please fill in the appropriate information. A CCC Counselor will contact you by the next business day (9-6 Mon-Wed, 9-7 Thur-Fri, 9-1 Sat EST) All information is handled confidentially.
 
General Information
E-mail address *(required field)
Your Full Name *(required field)
Spouse Name
StreetAddress
City
State
Zip
HomePhone *(required field)
Work or Cell Phone
Fax
How did you hear about us
Best Time of Day to call
Your Income
Monthly Take Home Pay
Spouse Take Home Pay
Other Income
Clients Employer
Expenses
Tithes Charity
Rent Mortgage
Lot Rent
Property Tax
Home Owners Renters
Electricity
Water/Sewer
Gas
Phone
Cable TV /Internet
Food
CarPayment 1
Gas Oil
Car Payment 2
Auto Insurance
Child Care Tuition
Other

Client Debt Information
Please fill in the Debt Summary using information from your most Current Statements. Our counselors work with all credit cards, department stores, gas cards, collections, Medical Bills, Auto, and other unsecured debts.		  
Comments-Please let us know about any urgent issues
(such as anticipated changes in your income or expenses.
Creditor Name
 Debt Type Current Balance Interest Rate
(APR)		 Amount Delinquent Minimum Payment  
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Credit Counselors Corp., Credit & Debt Counseling, Fort Wayne, IN
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