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 appointment day."
Items marked with an asterisk (*) are required.
Budget Information Worksheet
*Name:
Name:
*Address:
*City:
*State
*Zip code
Phone:
E-mail:
Residence:
Own -
Buying -
Renting
Other
Dependants: #
Ages:
separate ages with a comma (,)
Employment/Income
Occupation:
Employer
Monthly Net Income
Occupation:
Employer
Monthly Net Income
Pension:
Alimony
Government:
Child Sup.
Other
Social Security
Monthly Living Expenses
Rent/Mortgage:
Daycare
Second Mortgage
Allowances
Assoc. Dues
Activities
Property Taxes
Diapers
Lot Rent
Child Support (outlay)
Gasoline
Car Payment
Car Maintenance
Student Loans
Registration/Taxes
Cosigned Loans
Groceries
Bank Acct. Deductions
Dining Out
Taxes
Optical/Eye Glasses
Business Cards
Food at work
Other
School Lunches
Tithes
Electric/Gas
Charities
Water/Sewer/Trash
School Tuition
Telephone
School Books
Pager/Cell Phone
School Supplies
Internet Service
Books/Newspaper
Cable TV/Satellite
Movies/Entertainment
Clothing
Gifts/Holidays
Laundry Expenses
Travel
Auto Insurance
Alcohol/Tobacco
Medical Insurance
Job Related/Tools
Life Insurance
Job Related/Other
Home/Renters Ins.
Home Maintenance
Prescriptions
Home Cleaning
Doctor Visits
Parking/Bus Pass
Dentist Visits
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
Monthly Payment
Creditor
Balance
Monthly Payment
Creditor
Balance
Monthly Payment
Creditor
Balance
Monthly Payment
Creditor
Balance
Monthly Payment
Creditor
Balance
Monthly Payment
Creditor
Balance
Monthly Payment
Creditor
Balance
Monthly Payment
Creditor
Balance
Monthly Payment
Creditor
Balance
Monthly Payment
Creditor
Balance
Monthly Payment
Creditor
Balance
Monthly Payment
Creditor
Balance
Monthly Payment
Creditor
Balance
Monthly Payment