Debt Management Form

Welcome to the Debt Management Form. This is the same form you would fill out prior to any appointment with a counselor. It’s used by CCCS counselor’s to make recommendations about your financial situation. All information exchanged via our website is safe and secure. Information provided is for recommendation purposes only and you are under no obligation by filling out this form.No personal information will be shared with anyone outside CCCS.

Let's Get Started...


Getting Started:

Before you get started filling out the form, we recommend that you ensure you have all of your financial materials together. You will need your check register, bank statements, credit statements, mortgage/lease statements, W-2 Forms and tax receipts. We recommend that you block-out 30-45 minutes to complete the form. This will allow you to take your time and to be as accurate as possible.

You may notice a few Point your mouse to the question mark icons throughout the form for additional information to appear about that particular item. throughout the form. You can point your mouse to these questions marks for helpful information to appear about that particular item. Go ahead, try it here to see how it works.

Please read the following two forms then proceed to Step 1 of the form:

The CCCS Statement of Services
OPEN THE CCCS STATEMENT OF SERVICES

The CCCS Privacy Statement
OPEN THE CCCS PRIVACY STATMENT

Step 1: Who You Are
I Verify before beginning this application, that I have read and understand the above CCCS Statement of Services and Privacy Statement.
Last Name: First Name: Middle Name: Also known as: Please provide any other names that you go by.
 
Social Security Number: Birthyear: Email Address:  
....................................................................................................................................................................................................................................................
Spouse's Last Name: If necessary, leave spouse information blank throughout the form. Spouse's First Name: Spouse's Middle Name: Also known as : Please provide any other names that you go by.
Social Security Number: Birthyear:    
   
....................................................................................................................................................................................................................................................
Address No./Street: City: Zip: Home Telephone:
 
How Long?:   Number in Family: Work Telephone:
     
        ....................................................................................................................................................................................................................................................
Savings Account Thrift Plan
     
IRA Stocks / Bonds
     
401K Cash Value of Life Insurance
 
Got questions about this section? Forward them to us using the additional comments box at the bottom of this form.




Step 2: What You Do
Employer: How long?

Pay Periods:
 Weekly
 Semi-Monthly
Address:
 Bi-Weekly
 Monthly
# of ExemptionsExemtions are the amounts that taxpayers can claim for themselves, their spouses and eligible dependents. There are two types of exemptions: personal and dependency. Each deduction reduces the income subject to tax. This amount changes from year to year. on W-4 Form: Form W-4, Employee's Withholding Allowance Certificate is completed by the employee and used by the employer to determine the amount of income tax to withhold.
City: State: Zip:  
Georgia
Telephone: Occupation:
...................................................................................................................................................................................................................................................
Spouse's Employer: How long?

Pay Periods:
 Weekly
 Semi-Monthly
Address:
 Bi-Weekly
 Monthly
# of ExemptionsExemtions are the amounts that taxpayers can claim for themselves, their spouses and eligible dependents. There are two types of exemptions: personal and dependency. Each deduction reduces the income subject to tax. This amount changes from year to year. on W-4 Form: Form W-4, Employee's Withholding Allowance Certificate is completed by the employee and used by the employer to determine the amount of income tax to withhold.
City: State: Zip:
Georgia
Telephone: Occupation:
Got questions about this section? Forward them to us using the additional comments box at the bottom of this form.
 





Step 3: Your House and Cars
Mortgage Company
Telephone Balance Owed
Loan Number Years Remaining
Are Taxes/Insurance Included?  
 Yes No Taxes and Insurance are often called an Escrow account.  
Are You Current? # of Months Delinquent
 Yes No
Second Mortgage Company / Equity Loan
Telephone Balance Owed
Loan Number Years Remaining
Are Taxes/Insurance Included? Market Value of Home
 Yes No Taxes and Insurance are often called an Escrow account.
Are You Current? # of Months Delinquent
 Yes No
........................................................................................................................................................................................................................
Auto
#1
Year:
Make/Model:
Purch./Lease Date:
Financed By:
Balance Owed:
  ........................................................................................................................................................................................................................
Auto
#2
Year:
Make/Model:
Purch./Lease Date:
Financed By:
Balance Owed:
  ........................................................................................................................................................................................................................
Auto
#3
Year:
Make/Model:
Purch./Lease Date:
Financed By:
Balance Owed:
  ........................................................................................................................................................................................................................
Got questions about this section? Forward them to us using the additional comments box at the bottom of this form.
 




Step 4: Who You Owe
Please be as thorough as possible. Please retain all credit statements as the counselor may
want to make copies at your appointment.

Creditor
#1

   Name: Address: Telephone:
Account Number: City: State: Zip Code:
Date Last Paid:This is the actual date that you last paid on this bill. It may be the same as the due date, or not. Balance Owed: Monthly Payment: Secured?:
Yes No
    .............................................................................................................................................................................................................

Creditor
#2

   Name: Address: Telephone:
Account Number: City: State: Zip Code:
Date Last Paid: This is the actual date that you last paid on this bill. It may be the same as the due date, or not. Balance Owed: Monthly Payment: Secured?:
Yes No
    .............................................................................................................................................................................................................

Creditor
#3

   Name: Address: Telephone:
Account Number: City: State: Zip Code:
Date Last Paid:This is the actual date that you last paid on this bill. It may be the same as the due date, or not. Balance Owed: Monthly Payment: Secured?:
Yes No
    .............................................................................................................................................................................................................

Creditor
#4

   Name: Address: Telephone:
Account Number: City: State: Zip Code:
Date Last Paid:This is the actual date that you last paid on this bill. It may be the same as the due date, or not. Balance Owed: Monthly Payment: Secured?:
Yes No
    .............................................................................................................................................................................................................

Creditor
#5

   Name: Address: Telephone:
Account Number: City: State: Zip Code:
Date Last Paid:This is the actual date that you last paid on this bill. It may be the same as the due date, or not. Balance Owed: Monthly Payment: Secured?:
Yes No
    .............................................................................................................................................................................................................

Creditor
#6

   Name: Address: Telephone:
Account Number: City: State: Zip Code:
Date Last Paid:This is the actual date that you last paid on this bill. It may be the same as the due date, or not. Balance Owed: Monthly Payment: Secured?:
Yes No
    .............................................................................................................................................................................................................

Creditor
#7

   Name: Address: Telephone:
Account Number: City: State: Zip Code:
Date Last Paid:This is the actual date that you last paid on this bill. It may be the same as the due date, or not. Balance Owed: Monthly Payment: Secured?:
Yes No
    .............................................................................................................................................................................................................

Creditor
#8

   Name: Address: Telephone:
Account Number: City: State: Zip Code:
Date Last Paid:This is the actual date that you last paid on this bill. It may be the same as the due date, or not. Balance Owed: Monthly Payment: Secured?:
Yes No
    .............................................................................................................................................................................................................

Creditor
#9

   Name: Address: Telephone:
Account Number: City: State: Zip Code:
Date Last Paid:This is the actual date that you last paid on this bill. It may be the same as the due date, or not. Balance Owed: Monthly Payment: Secured?:
Yes No
    .............................................................................................................................................................................................................

Creditor
#10

   Name: Address: Telephone:
Account Number: City: State: Zip Code:
Date Last Paid:This is the actual date that you last paid on this bill. It may be the same as the due date, or not. Balance Owed: Monthly Payment: Secured?:
Yes No
    .............................................................................................................................................................................................................

Creditor
#11

   Name: Address: Telephone:
Account Number: City: State: Zip Code:
Date Last Paid:This is the actual date that you last paid on this bill. It may be the same as the due date, or not. Balance Owed: Monthly Payment: Secured?:
Yes No
    .............................................................................................................................................................................................................

Creditor
#12

   Name: Address: Telephone:
Account Number: City: State: Zip Code: