Have you ever been counseled by CCCS?
If yes, when?
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Marital Status:
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APPLICANT INFORMATION:
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Last Name:
First Name:
Middle
Name:
Maiden/Former:
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Home Phone: |
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Daytime Phone: |
Home Address:
City:State:Zip:
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Cell Phone: |
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Email address :
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Occupation: |
Best way to reach you from 9:00 am to 5:00 pm by:
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Your Take Home Pay (Per Month):
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Number of Exemptions claimed on W-4: |
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SPOUSE INFORMATION:
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Last Name:First
Name:
Middle Name:Maiden/Former: |
Home Phone: |
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Daytime Phone: |
Home Address:
City:State:Zip: |
Cell Phone: |
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Email address : |
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Occupation: |
Best way to reach you from 9:00 am to 5:00 pm by:
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Your Take Home Pay (Per Month):
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Number of Exemptions claimed on W-4: |
Is any money being deducted from your pay for credit union loans, 401k savings,
etc?
If so, how much per month?
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List deductions from checking account each month?
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Have you ever filed for bankruptcy?If yes,
what year? |
What Chapter? |
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OTHER SOURCES OF INCOME (Amount Per Month): Total
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Child Support:
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Part-time Job:
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Unemployment Comp:
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Disability Comp:
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Annuity/Dividends/Other:
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Rentals/Boarders:
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Pension/Social Security:
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National Guard:
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HOUSING INFORMATION : |
Name of Mortgage Co./Contract Holder/Landlord :
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Is your rent/mortgage current?
If not, how many months delinquent?
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Balance 1st Mortgage: |
Appraised Value: |
Are property taxes current?
If not, how much is owed? |
Balance 2nd Mortgage: |
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MODEL BALANCE VALUE: List all Autos, Boats, RV’s, Motorcycles by Year and Make |
Property Model
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Model
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Model
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Model
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Balance on Property
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Balance
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Balance
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Balance
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Appraised Value
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Value
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Value
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Value
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INCOME TAX INFORMATION: Have last year’s taxes been filed? |
Do you owe the IRS for prior years? |
Amount Owed:
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Amount of refund:
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What arrangements have been made?
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