Cdmn_PersInfo

CDMN

Personal Information

Last Name:			First Name:				Middle Name:
Address:			City:				State:		Zip:
Social Security Number: – –			Home Phone: ( )				E-mail:
Housing:	Own[ ]	Rent[ ]			Marital Status:		S [ ]	M [ ]	D [ ]	W [ ]
Currently working:	Yes [ ]	No [ ]	Date of Birth:				Fax: ( )
Employer:					Occupation:				How long?
Address:			City:				State:		Zip:

Spouse Information:
Last Name:			First Name:				Middle Name:
Social Security Number: – –			Home Phone: ( )				E-mail:
Currently working:	Yes [ ]	No [ ]	Date of Birth:
Employer:					Occupation:				How long?
Address:			City:				State:		Zip:

Salaries and Wages:
When do you get paid?			Weekly: $		Biweekly: $		2X Monthly:$		Monthly: $
Your spouse?			Weekly: $		Biweekly: $		2X Monthly:$		Monthly: $
Are you Currently involved in?			Lawsuits		Garnishments		Back Taxes		If so, indicate amount
			Yes [ ]	No [ ]	Yes [ ]	No [ ]	Yes [ ]	No [ ]	$
Number of Dependants:

Reason for Debt Management Plan:
[ ]Poor Money Management					[ ]Death in Family
[ ]Reduced Income					[ ]Medical Reasons/ Disability
[ ]Divorce or Separation					[ ]Confidential