West Oak Settlement

Creditor Worksheet
Client Name:		Spouse Name:
Address:		City:
State:		Zip:
Day Time Phone:		Evening Time Phone:

Please fill in all spaces on this application. In order to put together a strategy and program that is right for you we need to know a little more about your debt. Please fill out the blanks below to the best of your ability

*NOTE: Credit Card Number not required for pre-approval

1. What happened in your life that has made it difficult to continue with your current payments?

Illness	Loss Job	Late Fees	High Interest Rates
Death In Family	Divorce	Other

2. Would reducing your current monthly payments by 30% help you?	Yes	No
3. Do you plan to buy a home or refinance within the next 24 to 36 months?	Yes	No
4. Do you plan to buy a car within the next 24 to 36 months?	Yes	No
5. Which of the below solutions have you considered to tackle this debt? Bankruptcy New Loan Debt Settlement/Negotiation Credit Counseling

6. Would being debt free in 24 to 36 months have a significant impact on your life?	Yes	No
7. Do you know your FICO/Credit Score?	Yes	No

Creditors	Account #	Current Balance	Payment Late
		$
		$
		$
		$
		$
		$
		$
		$
		$
		$

Important Notice

The information on this worksheet relating to your debts is preliminary. We will update it based on the information obtained during a personal interview with you, and information contained in your credit report. We will recompute your fees and prepare a Schedule of Program Debt, which is incorporated into your contract. A copy will be included in your Program Guide.

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