Providing Community Services: Dedicated to Financial Literacy

Budget Analysis Form

Step 1 of 4: Personal Information

For counseling in Peoria, Decatur, Champaign, Danville, Princeton, Galesburg, or Springfield, please call: 1-888-671-2227

To submit an application for our budget analysis services, please fill out the 4-step form starting below with your personal information. Or, if you prefer, download the PDF version and fax it back to us or mail it to our offices.

PERSONAL INFORMATION
Your Information

Last Name

First/Middle Name

Maiden Name

Date of Birth

Social Security No.

Spouse's Last Name

First/Middle Name

Maiden Name

Date of Birth

Social Security No.
Property Information

Address

City

State

ZIP Code

County

Email

Primary Phone

Alternate Phone

How long have you lived at this address?

Check one:  Own   Rent   Buying   Other

1st Mortgage paid to:

Approximate Balance:

2nd Mortgage paid to:

Approximate Balance:

Delinquent Rent/Mortgage:  Yes   No

If yes, number of months:

Amount:

Fair market value of house:

Total Assets:
Family Status

Please check one:  Married   Single   Widowed   Divorced   Separated

Number of dependent children:

Ages:
Employment

Employer:

Position:

Spouse's employer:

Position:
Automobile(s)

Vehicle 1

Make:

Model:

Year:
 

Vehicle condition

Monthly Payment:

Still Owe:

Vehicle 2

Make:

Model:

Year:
 

Vehicle condition

Monthly Payment:

Still Owe:
Bankruptcy

Have you ever filed for bankruptcy?  Yes   No

   

*By submitting this application, I/we authorize the release of information contained within this form to be used and discussed with our creditors on our behalf.