mydebtsolution.com - Debt solutions. On Line. Anytime.

Tuesday, March 16, 2010

This is our most recommended option for a complete financial review, at no cost, with your personal Credit Consultant.

To get started, please complete and submit the detailed information form below. All information will be completely secure and confidential.

Your personal Credit Consultant will contact you directly within 24 hours to begin the review together with you. Please indicate any time or date preferences for contact.

Note: ** items are required fields to assure a prompt review and reply.

My Contact and Personal Information

How did you find mydebtsolution.com?

Date:

Name (Last, First): **

Email Address: **

Date of Birth (mm/dd/yyyy):

Spouse's Name (Last, First):

Spouse's DOB (mm/dd/yyyy):

Dependants:

Number Ages

Res. Phone (incl. area code): **

Work Phone (incl. area code):

Cell Phone (incl. area code):

Time Zone:

Preferred Contact Time / Date:

Street Address:

City: **

Province: **

Postal Code:

Length at Present Address:

Living Arrangements:
if other, please specify

My Employment Information

Employer:

Location:

Length at Employer:

Occupation:

Spouse Employer:

Location:

Length at Employer:

Occupation:

My Monthly Expenses **

Rent:			Auto Payment:
Mortgage:			Auto Insurance:
Property Taxes:			House Insurance:
Strata Fees:			Life Insurance:
Hydro:			Health Insurance:
Gas / Oil Heating:			Prescriptions:
Phone / Cell:			Child Care Support:
Cable / Net:			Entertainment:
Food:			Alcohol / Tobacco:
Clothing:			Other:
Transportation: ie: gas, repairs, public transit

My Monthly Income **

Take Home Pay:

Spouses Take Home Pay:

Child Tax Credit:

Other:

My Unsecured Creditors **

Please list all credit cards or consumer creditors who do not hold registered collateral.

Financial Institution:

Type of Credit:

Balance Owing:

Monthly Payment:

Financial Institution:

Type of Credit:

Balance Owing:

Monthly Payment:

Financial Institution:

Type of Credit:

Balance Owing:

Monthly Payment:

Financial Institution:

Type of Credit:

Balance Owing:

Monthly Payment:

Financial Institution:

Type of Credit:

Balance Owing:

Monthly Payment:

Financial Institution:

Type of Credit:

Balance Owing:

Monthly Payment:

Financial Institution:

Type of Credit:

Balance Owing:

Monthly Payment:

Financial Institution:

Type of Credit:

Balance Owing:

Monthly Payment:

If there are not enough spaces to list all of your unsecured creditors, use either the secured creditor area or the notes and comments sections below.

My Secured and /or Cosigned Creditors **

Please list all creditors that have registered collateral such as a home mortgage, auto loan or debts cosigned by a third party.

Financial Institution:

Type of Credit:

Balance Owing:

Monthly Payment:

Collateral Security and/or Cosigner Name:

Financial Institution:

Type of Credit:

Balance Owing:

Monthly Payment:

Collateral Security and/or Cosigner Name: