(For proper evaluation please submit information from BOTH worksheets.)
Name:
Mr.
Mrs.
Ms.
Phone: (Please include area code)
Creditor
Current Balance
Current Payment
1.
$
$
2.
$
$
3.
$
$
4.
$
$
5.
$
$
6.
$
$
7.
$
$
8.
$
$
9.
$
$
10.
$
$
11.
$
$
12.
$
$
All information will be kept confidential. A counselour will contact you as soon as information is received and your accounts are verified and configured for our plan. Thank you for choosing CBC.
(For proper evaluation please submit information from BOTH worksheets.)