American Credit Foundation® Consumer Credit Counseling

Complete this form, then use the "Encrypt Now" button to send the Secured form to American Credit Foundation^®.

Your enrollment documentation will be reviewed by one of our counselors and you will be contacted by your counselor within one (1) business day for verification of payment amounts and the payment date.

Applicant Information

Client

* Required Fields

Last Name:*
First Name:*
E-mail Address:*
Address:*
Address:
City:*
State:*	Zip Code:*
Home Phone:*
Work Phone:*
Occupation:
Employer:
Social Security #:*	*Net Income:
Income Source:
Sex:*	Male Female Age:
Marital Status:*	No. of Dependents:
Level of Education:	Rent Own
Referred by:
Cause for Financial Situation:
Spouse
Last Name:
First Name:
Work Phone:
Occupation:
Employer:
Social Security #:	*Net Income:
Sex:	Male Female Age:
Level of Education:

You may wish to gather your most recent creditor statements at this point.
These statements should provide the necessary information required below.

Types of debt eligible for the debt management program:

Please do not include: Home Loans, Auto Loans, or Student Loans. Secured debts cannot be added to the program. The following are examples of unsecured debt that can be included on the program:

Credit Cards
Department Store Cards
Finance Company Loans
Medical Bills
ETC�

Creditor Summary

Creditor Name

Account No

Account
Balance

Interest
Rate

Minimum
Payment

Creditor
Phone #

Date
Last Paid

Monthly Spending Plan * Add back any expenses deducted from payroll ** List any payroll deductions on the monthly spending plan *Net Income
Employment Income
Income From Other Sources
Total Net income (Employment Income + Income from Other Sources)
**Expenses
Mortgage/Rent Payment
Second Mortgage
Homeowners/Renters Insurance
Utilities (electricity, gas, heat, water, sewer)
Telephone
Home Maintenance
Total Car Payments
Gas/Oil/Registration
Auto Insurance
Clothing
Babysitting/Childcare
Alimony/Child Support Payments
Food & Household Items
Life Insurance
Medical Insurance
Monthly Medical Needs
Contributions/Religious
Taxes (property)
Taxes (other)
Miscellaneous
Other
Other
Subtotal
Total Minimum Monthly Expenses From Creditor Summary
TOTAL EXPENSES (subtotal plus total from creditor summary)
BALANCE (total net income minus total expenses]
Include any expenses deducted from payroll other than those listed on Creditor Summary

*I would prefer to make my monthly payments on the: (day of month) of each month. Starting in the month of: (month name).
*Are there any pending judgments or garnishments?	Yes No
*Have you ever declared bankruptcy?	Yes No
If so, what year?
Are there any pending IRS problems?	Yes No
If so, please explain:

By clicking on the Encrypt Nowbutton, YOU UNDERSTAND:
That it is your responsibility to make timely payments in guaranteed funds under your repayment plan. That the debt management program may not prevent further collection efforts taken against me by my creditors. That American Credit Foundation^® may receive contributions from my creditors to help cover it's operating costs. That American Credit Foundation^® has made no warranty, promise or guarantee to me as to the results which may be obtained in my particular case.

By clicking on the Encrypt Nowbutton, YOU AUTHORIZE:
American Credit Foundation^®, a non-profit organization, to obtain all information from my creditors, or credit reporting agencies, and to negotiate with my creditors to compromise or work out a payment structure for my existing obligations. That the electronic results of this submission, or a photocopy or facsimile transmission thereof, shall serve as a release to allow American Credit Foundation^® to obtain all necessary information from my creditors. I agree to pay $30.00 per month to American Credit Foundation^® to help defray the costs of servicing my account. I agree to hold American Credit Foundation^®, its officers, directors, employees, and agents harmless from any claim, suit, action or demand arising form the services provided by American Credit Foundation^® to me. This agreement shall be governed in accordance with the laws of the state of Utah.

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