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Type of Debt
 (Select all that apply):

Credit Card Debt	Medical Bills
Choose Amount $2,000 to $5,000 $5,000 to $10,000 $10,000 to $15,000 $15,000 +	Choose Amount $0 to $2,000 $2,000 to $5,000 $5,000 +
Accounts in Collections	Disconnected Utilities
Choose Amount $0 to $2,000 $2,000 to $5,000 $5,000 +	Choose Amount $0 to $2,000 $2,000 to $5,000 $5,000 +
Number of Late Payments	Average Monthly Payment
Never Late 1 late payment 2 late payments 3+ late payments	Select Amount less than $40 $40 - 100 $100 - 150 $150 - 200 $200 - 250 $250 - 300 $300 - 350 $350 - 400 $400 - 450 $450 - 500 $500 - 550 $550 - 600 $600+

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Best time to call*	Do you have your statements?
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