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Personal Financial Worksheet
(*) Required Field

* Applicant First Name: * Applicant Last Name: * Applicant Email Address:
Applicant SS#: Applicant Birthdate:  
   
Co-Applicant First Name: Co-Applicant Last Name: Relationship to Applicant:
Co-Applicant SS#: Co-Applicant Birthdate:  
 
Address: City: * State:
Zip Code: * Home Phone: Work Phone:
EXT.
Total number of people in household:
Total amount of your Unsecured Debts:
What is the best time to reach you?:
 
Monthly Income:
Applicant Occupation:

Applicant Employer:

Applicant Wages (net): $ Applicant Int/Dividends: $
Applicant Social Security: $ Applicant Other Income:
Please Specify: 		$
Co-Applicant Occupation: Co-Applicant Employer:
Co-Applicant Wages (net): $ Co-Applicant Int/Dividends: $
Co-Applicant Social Security: $ Co-Applicant Other Income:
Please Specify: 		$
Monthly Expenses - Housing:

Rent:

 $ Mortgage: $
Electric/Gas: $ Water/Garbage: $
Property Taxes: $ Telephone (home, cell): $
Miscellaneous: $ Cable TV & Internet: $
Monthly Expenses - Insurance and Food:
Auto Insurance: $ Home Insurance: $
Life Insurance: $ Health Insurance: $
Miscellaneous (insurance): $ Dining Out: $
Groceries: $ Miscellaneous (food): $
Monthly Expenses - Other:
Savings Contributions: $ Clothing: $
Debt Payments: $ Car Payments: $
Transportation (gas, oil): $ Vacation: $
Gifts: $ Education: $
Medical/Dental: $ Newspapers/Magazines: $
Videos/CDs/Tapes: $ Personal Services: $
Alcohol/Tobacco: $ Children's Expenses: $
Charity/Church Giving: $ Child Care: $

Assets (Real Estate and Vehicles):
Property Description: Market Value: Monthly Payment: Current Balance: Interest Rate:

%
%
%
%
%
 

Creditor #1
Creditor Name:
Current Balance:
Payment Amount:
Interest Rate: %
Account Number:
Account Owner:
Type of Account:
Months Delinquent:
 

Creditor #2
Creditor Name:
Current Balance:
Payment Amount:
Interest Rate: %
Account Number:
Account Owner:
Type of Account:
Months Delinquent:
 

Creditor #3
Creditor Name:
Current Balance:
Payment Amount:
Interest Rate: %
Account Number:
Account Owner:
Type of Account:
Months Delinquent:
 

Creditor #4
Creditor Name:
Current Balance:
Payment Amount:
Interest Rate: %
Account Number:
Account Owner:
Type of Account:
Months Delinquent:
 

Creditor #5
Creditor Name:
Current Balance:
Payment Amount:
Interest Rate: %
Account Number:
Account Owner:
Type of Account:
Months Delinquent:
 

Creditor #6
Creditor Name:
Current Balance:
Payment Amount:
Interest Rate: %
Account Number:
Account Owner:
Type of Account:
Months Delinquent:
 

Creditor #7
Creditor Name:
Current Balance:
Payment Amount:
Interest Rate: %
Account Number:
Account Owner:
Type of Account:
Months Delinquent:
 

Creditor #8
Creditor Name:
Current Balance:
Payment Amount:
Interest Rate: %
Account Number:
Account Owner:
Type of Account:
Months Delinquent:
 

Creditor #9
Creditor Name:
Current Balance:
Payment Amount:
Interest Rate: %
Account Number:
Account Owner:
Type of Account:
Months Delinquent:
 

Creditor #10
Creditor Name:
Current Balance:
Payment Amount:
Interest Rate: %
Account Number:
Account Owner:
Type of Account:
Months Delinquent:
 
* Please indicate your primary reason(s) for applying:
Over-obligation (Excessive Spending)
Unemployment--Loss of Income
Reduced Income
Unexpected Medical Costs
Accident/Disability		 Gambling
Divorce/Separation
Other (Please Specify)
     
   

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