First Name
Last Name
Zip Code
Email Address
Telephone
Alternative Telephone - Mobile/Work
Address
State	Select Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware Dist of Columbia Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming
City
Are you?	Employed Self Employed Not Working Retired
Do You have any credit card debt?	Yes No
How much credit card debt do you have?	Select $10,000 - 12,499 $12,500 – 14,999 $15,000 – 19,999 $20,000 – 29,999 $30,000 – 39,999 $40,000 – 49,999 $50,000+
How far are you behind on your credit card payments?	Select Not Behind 1-3 Months 4-6 Months 6 Months +
Do you have any tax debt?	Yes No
How much tax debt do you have?	Select $10,000 - 12,499 $12,500 – 14,999 $15,000 – 19,999 $20,000 – 29,999 $30,000 – 39,999 $40,000 – 49,999 $50,000+
What is your tax problem?	Select Unable to pay taxes Tax Return Unfiled Bank Account Levy Owe Payroll Taxes Lien Filed Audit Notice Customer Payed Levied Spouse in Trouble Garnished Wages Assets Seized Other
Is your tax federal, state or both?	Select Federal State Federal and State
What is your type of tax?	Select Personal Business Business and Personal Payroll
Has your tax been filed?	Filed Not Filed
Have you considered bankruptcy?	Yes No
What would be the main reason you would consider bankruptcy?	Select Loss of Income Illness Creditor Harassment Repossession Foreclosure Lawsuits Other
Do you have a mortgage?	Yes No
Are you behind on your mortgage payments?	Yes No
Do you know what your credit rating is?	Select Excellent 720+ Good 660-719 Fair 580-659 Poor 579 and less
What is your annual income?	Select $0 - 5,000 $5,000 – 10,000 $10,000 – 20,000 $20,000 – 30,000 $30,000 - 40,000 $40,000 – 50,000 $50,000 – 60,000 $60,000 – 70,000 $70,000 – 80,000 $80,000 – 90,000 $90,000 - 100,000
What is your home type?	Select Single Family Home Condo Town Home Multi Family Dwelling Duplex Mobile Home Trailer
What is the value of your property?	Select $100,000–150,000 $150,000–200,000 $200,000–250,000 $250,000–300,000 $300,000–350,000 $350,000–400,000 $400,000–450,000 $450,000–500,000 $500,000–550,000 $550,000–600,000 $600,000–650,000 $650,000–700,000 $700,000–750,000 $750,000–800,000 $800,000–850,000 $850,000–900,000 $900,000–950,000 1 million +
What is your mortgage balance?	Select $100,000–150,000 $150,000–200,000 $200,000–250,000 $250,000–300,000 $300,000–350,000 $350,000–400,000 $400,000–450,000 $450,000–500,000 $500,000–550,000 $550,000–600,000 $600,000–650,000 $650,000–700,000 $700,000–750,000 $750,000–800,000 $800,000–850,000 $850,000–900,000 $900,000–950,000 1 million +
Do you have a fixed or adjustable loan amount?	Select Fixed Adjustable Don't Know
What is your mortgage interest rate?
How much cash would you like to borrow additionally?	Select $5,000–20,000 $20,000–40,000 $40,000–60,000 $60,000–80,000 $80,000–100,000 $100,000–120,000 $120,000–140,000 $140,000–160,000 $160,000–180,000 $180,000–200,000 $200,000–220,000 $220,000–240,000 $240,000–260,000 $260,000–280,000 $280,000–300,000 $300,000–320,000 $320,000–340,000 $340,000–360,000
What is the name of your current lender?
Based on the answers you have given so far, you have been pre qualified to receive a debt consolidation loan up to $1500, would a debt consolidation loan be helpful to you right now?	Yes No
How much cash would you like to borrow - up to $1,000?
How long have you live at your current address?
What is you date of birth?
What is you social security number?
What is you drivers license or state ID#?
Do you own a home?	Yes No
Who is you current employer?
What is the telephone of your employer (we do not call them)?
How long have you been employed there for?
How often are you paid?
When is your next pay day?
How do you receive your pay check?
What is your monthly income?
Do you have a checking or a savings account where we can wire you your cash?
How long have you had this bank account for?
What is you ABA routing number?
What is your account number?
What is the name of the bank?
What is the telephone number of your bank?