Consumer Credit & Budget Counseling's

Budget Analysis Form

You should use the SECURE form below to submit your budget for a:

Free, No Obligation, No Cost, and Confidential Budget Analysis

We have also included a Net Worth Statement. (This is required by some creditors for acceptance in a Debt Management Program, if you are only applying for a Budget Analysis you can omit this information)

If you prefer you can print out this form and fax it to our toll free fax 1-888-738-8234

Contact Information

We collect this information only to return your analysis to you, or contact you with any questions we may have about your situation, all collected information will remain confidential.

You will need to either include your e-mail address, fax number or street address so that we have a means to return your free personalized Debt Management Program to you.

Name
 *-required
Street Address
Address (cont.)
City
State
Zip/Postal Code
Contact Phone
Fax
e-mail
 *-required

Budget Information

Please fill out this form as completely as possible with your net monthly income and expenses. A qualified budget counselor will review your situation and send you a complete analysis of your budget with money saving tips absolutely FREE, with no obligation what so ever.

Monthly Income    
(Please list Monthly net)
Income Applicant
 
Income Partner
 
Other Income
  # of Persons in Household
Monthly Expenses    
Housing:
Mortgage / Rent
 
2nd Mortgage
 
Electric
 
Gas / Oil
 
Water / Sewer
 
Telephone
     
Food:
Groceries
 
At Work / School
 
Dining Out
     
Child Care:
Day Care / Sitters
 
Child Allowance
 
Support / Alimony
     
Education:
Tuition
 
Lessons
 
Student Loans
     
Entertainment:
Cable TV
 
Movies
 
Sports
     
Transportation:
Auto Payment(s)
 
Auto Insurance
 
Gas
 
Tolls / Parking
 
Public Transportation
 
Maintenance
     
Clothing:
Family
 
Laundry / Cleaners
     
Medical:
Doctor / Dentist/ Health Ins
 
Prescriptions
     
Other:
Hair Care / Beauty
 
Gifts
 
Vacations
 
Life Insurance
 
Church / Temple
 
Pet Care
 
Tobacco / Alcohol
 
Other Expenses
     
Savings / Debt:
Savings
 
Debt Payments (monthly)
     
Net Worth Statement
    
Assets:
Balance of Bank Accounts
 
Stocks & Bonds
 
Life Insurance Cash Value
 
Value of Real Estate Owned
 
Vested Retirement Funds
  Value of Automobile (s)
  Other Assets
     
Liabilities
 Mortgage Balance
  Auto Loan Balance
  Total Credit Card Balance
  Personal Loan Balance
  Judgments/Collections

 

Please submit any additional information that you feel may be helpful:

You should expect a response by e-mail in Adobe PDF format within three to four business days