Apply For Payments

This is an attempt to collect a debt by a debt collector and any information obtained will be used for that purpose.

Payment Information

Amount you wish to make payments on^*

Down payment amount offered^*

Monthly amount^*

Personal Information

Name^*

Number of dependents (including yourself)^*

Spouse's Name

Address^*

City & State^*

Zip Code^*

Email.

Home Phone^*

Cell Phone

Employer Information

Employer^*

Phone^*

Address^*

City^*

State^*

Zip Code^*

Occupation^*

Date Employed^*

Gross Salary^*

Pay Period^*

Monthly

Weekly

Bi-Weekly

Annually

Spouse's Employer Information

Employer^*

Phone^*

Address^*

City^*

State

Zip Code^*

Occupation^*

Date Employed^*

Gross Salary^*

Pay Period

Monthly

Weekly

Bi-Weekly

Annually

Other Income

( Commissions, rents, pensions, welfare or ADC, Military, Social Security, 2nd job, etc.)

Source 1

Amount

Source 2

Amount

Source 3

Amount

Life Insurance

Life Insurance Company

Face Amount

When Purchased

Banking Information

Checking account 1 at

Amount

Checking account 2 at

Amount

Savings Account 1 at

Amount

Savings Account 2 at

Amount

Credit Card? Credit Limit

Amount Owed

Additional Credit Card? Credit Limit

Amount Owed

Stocks/Bonds/CD's/IRA's: Amount or Value

Company or Bank

Relative Information

Name of nearest relative not living with you^*

Relationship^*

Address^*

City^*

State^*

Zip Code^*

Home Phone^*

Home Information

Renting

Owning/Buying

Landlord Phone (if renting)

Rent Payment

Financed by: 1st Mortgage

City and State

Financed by 2nd Mortgage

City and State

Monthly Payment

Purchase Price

Other real estate

Address or description

Amount Owing

Monthly Payment

Purchase Price

Year Purchased

Motor Vehicles Owned

included cars, trucks, tractors , etc..

Title in name of

Make

Model

Year

Balanced owed

Monthly Pmt

Owed to

Title 2 in name of

Make

Year

Balanced owed

Monthly Pmt

Owed to

Title 3 in name of

Make

Model

Year

Balance owed

Monthly Pmt

Owed to

Title 4 in name of

Make

Model

Year

Balance owed

Monthly Pmt

Owed to

Title 5 in name of

Make

Model

Year

Balance owed

Monthly Pmt

Owed to

Title 6 in the name of

Make

Model

Year

Balance owed

Monthly Pmt

Owed to

Title 7 in name of

Make

Model

Year

Balance owed

Monthly Pmt

Owed to

Title 8 in name of

Make

Model

Year

Balanced owed

Monthly Pmt

Owed to

Title 9 in name of

Make

Model

Year

Balanced owed

Monthly Pmt

Owed to

Miscellaneous Property Owned

include guns, riding lawn mowers, TV's, VCR's, Pianos and Organs, sporting goods, etc..

Model

Model or name

Description

Model 2 or Name

Description

Model 3 or Name

Description

Model 4 or Name

Description

Model 5 or Name

Description

Model 6 or Name

Description

Other Bills Owed

Including- banks, finance companies, credit cards, medical bills or others not previously listed

Owed to

Amount

Payments

Owed to 2

Amount

Payment

Owed to 3

Amount

Payment

Owed to 4

Amount

Payment

Owed to 5

Amount

Payments

Owed to 6

Amount

Payments

Other Information

Ever filed bankruptcy?^*

Yes

Ever been sued?^*

Yes

Paying child support?^*

Yes

If yes, amount paid

Any outstanding judgements?^*

Yes

Signature

Applicant Signature^*

Date^*

Spouse's Signature

Date