Fidelity Credit Counseling - A Non-Profit Organization

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* Fields marked with an asterisk are required.

First Name

Last Name

Day Phone

--*

Night Phone

State

Email Address

Approximate Total Amount Of Unsecured Debt?	*
(ie: Credit Cards, Personal Loans, Collection Agencies, etc.)

Are Your Bills Current Or Past Due?	*

If Bills Past Due, For How Long?

How Would You Rate Your Credit?	*

Do You Own Or Rent?	*

Is Your Mortgage Current Or Past Due?

Best Time To Contact You:	*

--------------- Creditors You Owe ---------------

Creditor #1

Balance Owed

Monthly Payment

Months Behind

Creditor #2

Balance Owed

Monthly Payment

Months Behind

Creditor #3

Balance Owed

Monthly Payment

Months Behind

Creditor #4

Balance Owed

Monthly Payment

Months Behind

Reason for Applying

Click any boxes below that describe your debt:

( Press Submit button only once )