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:
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
   
Do You Owe Additional Creditors? Yes No
     

(If yes, please supply additional information at Additional Comments at
the bottom of the form.)

 
   




Step 5: What's Coming In
Be sure to figure all dollar amounts monthly.
(Please calculate amounts manually) Client Spouse Total
Monthly Gross Income
(Income before Taxes & Deductions)
..............................................................................................................................................................................................................................

Taxes, F.I.C.A. (SSI & Medicare)
Insurance (Health & Life)

..............................................................................................................................................................................................................................

Other Deductions: (Retirement, Savings, Profit
Sharing,Credit Union Loans, Credit Union Savings)

..............................................................................................................................................................................................................................

Total Deductions
..............................................................................................................................................................................................................................
Monthly Take Home
Gross Income less Total Deductions
...................................................................................................................................................................................................................................................
Other Income (Child Support, Military Retirement, Alimony, Part Time Job, etc.)

..............................................................................................................................................................................................................................
Net Income
(Monthly Take Home plus Other Income)
  ......................................................................................................................
  Total Monthly Net Income
Got questions about this section? Forward them to us using the additional comments box at the bottom of this form.



Step 6: What's Going Out

Property:
Rent or Mortgage Payments:
Equity Loan / Second Mortgage / Land Payment / Lot Rent
Property Taxes & Insurance, Assoc. Fees / Dues
(if not included in mortgage), Renter's Insurance
Home Maintenance:
house repairs, lawn / garden, pool, security monitoring, pest / termite control

...................................................................................................................................................................................................................................................

Utilities: you may average your utilities payment

Gas:
Electicity:
Water/Sewer:
Garbage:

...................................................................................................................................................................................................................................................

Communications:
Basic Phone:
Long Distance :

Cell Phone:
Pager:
Internet:
Cable:

...................................................................................................................................................................................................................................................

Groceries:
Groceries:
Food, beverages, pet food
Household Items:
cleaning supplies, paper products, diapers, toiletries, cosmetics, detergent
Lunches Away From Home:
School Lunches:
Dining Out:

...................................................................................................................................................................................................................................................

Insurance:
this is insurance not included anywhere else on the form. Do not include
any insurance through your employer here, please place that in Step 5.

Life
Medical

...................................................................................................................................................................................................................................................

Transportation:
Please be sure to fill in the transportation amounts again.

Car Payment: 1st Vehicle
Car Payment: 2nd Vehicle
Car Payment: 3rd Vehicle
Auto Insurance Monthly Payment
Tag / Ad Valoremn Taxes Ad Velorem is a tax which varies based on the value of the product, service or property on which it is levied.
Fuel
Parking / Tolls
Maintenance / Repairs
Public Transportation Fair
Cab Fair
Other

...................................................................................................................................................................................................................................................

Medical / Family Care / Education:
Monthly Medical & Prescription Bills
CoPay Medical
Dental
Optical
Alimony and / or Child Support
Child Care / Elder Care
Education: Tuition, books, supplies, special lessons,
pictures, yearbooks

...................................................................................................................................................................................................................................................

Personal:
Laundry & Dry Cleaning
Clothing: New and Replacement shoes, hose,
jewelry/accessories, undergarments
Beauty & Barbershop: Nails, haircuts, hair coloring
Personal Expenses: Tobacco, liquor, beer, wine
(if not included in groceries)
Club & Union Dues, Health or Sports Memberships AAA, Licenses
Contributions: charities, church donations, tithe
Recreation: movies, video rental, entertainment, music / concerts / CD's, tickets,
sports, vacations / travel / family visits, hobbies, lottery
Gifts / Cards birthdays, Mother's / Father's Day, weddings / anniversaries, holidays (Christmas, Hanukkah, other):
Bank Charges :
Other:

Got questions about this section? Forward them to us using the additional comments box at the bottom of this form.

Additional Comments:

 

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