Consumer Credit Counseling Service, Inc.

 Plans that work.  People who care.

 

For an appointment, please complete the following form and press the “submit” button, at the bottom of the page.  The information will be forwarded to our agency and you will then be contacted to set up an appointment.  

 

The $25 counseling fee is due in our office by your counseling day.

Budget Information Worksheet

Name:

Name:

Address

City

State

Zip code

Phone Number

E-mail Address

Employment/Income

Occupation

Employer

Monthly Net Income

Occupation

Employer

Monthly Net Income

Pension

Alimony

Social Security

Government

Child Sup.

Other

Monthly Living Expenses

Rent/Mortgage

Second Mortgage

Assoc. Dues

Property Taxes

Lot Rent

Gasoline

Daycare

Allowances

Activities

Diapers

Child Support

Car Payment

Car Maintenance

Registration/Taxes

Groceries

Dining Out

Food at work

School Lunches

Electric/Gas

Water/Sewer/Trash

Telephone

Pager/Cell Phone

Internet Service

Cable TV/Satellite

Clothing

Laundry Expenses

Auto Insurance

Medical Insurance

Life Insurance

Home/Renters Ins.

Prescriptions

Doctor Visits

Dentist Visits

Optical/Eye Glasses

Student Loans

Cosigned Loans

Bank Acct. Deductions

Taxes

Business Cards

Other

Tithes

Charities

School Tuition

School Books

School Supplies

Books/Newspaper

Movies/Entertainment

Gifts/Holidays

Travel

Alcohol/Tobacco

Job Related/Tools

Job Related/Other

Home Maintenance

Home Cleaning

Parking/Bus Pass

Personal—hair care

Postage

Bank Charges

Pets

Debts—list all debts: mortgages, vehicle loans, credit cards, collections, medical, etc.

Creditor

Balance

Monthly Payment

Creditor

Balance

Monthly Payment

Creditor

Balance</