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					                  Credit Counseling Referral Form
Information for the consumer: By paying their bills through a debt management
company, they will repay their credit card debt 100%. The main benefit with a debt
management company is reducing their current interest rates and getting their debt paid off
in just 3-5 years. Other benefits offered through a Debt Management Program are:

      One low monthly payment
      Reducing interest rates
      Eliminating Late and Over limit Fees
      Stopping harassing phone calls
      Debt free in just 3-5 years

Quick questions to qualify a Potential Coastal Client:

      How much unsecured debt do you have? (Must be 5k or higher)
      What type of debt? (IE: Secured or Unsecured) - must be unsecured: IE: Credit
       cards
      Are you current or behind? (0-3mos – must know who they owe)
      Do you have money coming in? (Client must be able to afford minimum 2% of
       their balance on a monthly basis.)
      Are you interested and serious about taking care of your bills?

If “Yes” to these questions – Fill out this sheet, sign it, then email or fax it
to your Account Executive.

Client Name:
Client Telephone 1:
Client Telephone 2:
Best Time To Call:


If your client agrees to enter the program you will be paid a referral fee that equals 20% of
the client’s first monthly payment into this program. This referral fee will only be paid once
the client has made the first payment into the program. The referral fee will only be paid to
the Authorized Broker which has signed this referral form.

Authorized Broker Signature:
Authorized Broker Printed Name:
Broker Code:
Telephone Number:

				
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