CCCS OF NORTHWEST INDIANA, INC. MEMBER NFCC 3637 GRANT STREET GARY INDIANA 46408 (219) 980-4800 FAX (219) 980-5012
Please fill out forms completely and bring them with you when you come for your appointment. INCOMPLETE FORMS WILL RESULT IN
RESCHEDULING YOUR APPOINTMENT.
CLIENT’S NAME____________________________ PHONE____________________
Soc. Sec. # Date of birth Employer Phone Position ___________________________ ___________________________ ___________________________ ___________________________ ___________________________ ____African American ____ Asian ____ Caucasian ____ Hispanic ____ Other ____ Married ____Single ____Divorced ____Separated ____Widowed
CO-APPLICANT_________________________________________
Soc. Sec. # ___________________________ Date of birth ___________________________ Employer ___________________________ Phone ___________________________ Position ___________________________ Housing ____Buy _____Rent Mortgage Company_____________________ ______________________________________ ____African American ____Asian ____Caucasian ____Hispanic ____Other Vehicles: Make/Year_________________ ___________________________________
Number of dependants______________Ages___________________________ Who referred you to our Agency? ________________________________________________________ Your appointment is with _______________________________________________________________ ______________________________________________________________________________________
Please bring with you!! _____Completed Forms _____Paycheck Stubs _____Statement from Creditors _____Housing Papers _____Foreclosure Letters
_______________________________________ _______________________________________ _______________________________________
MUST BE FILLED OUT COMPLETELY
Living Expenses Monthly Rent/House Payment ___________ 2nd Mortgage/Lot Rent ___________ Property taxes ___________ Homeowner/Renter Insurance ___________ Electric/Natural/LP Gas ___________ Water/Sanitation/Garbage ___________ Telephone/Cellular/Pager ___________ Groceries/Beverages/Toiletries/Soaps___________ Work Lunches/Snacks ___________ School Lunches/Snacks ___________ Auto Payments ___________ Auto Insurance ___________ Auto Repair/Maintenance ___________ Gasoline/Oil ___________ License Plates ___________ Public Transportation/Parking/Tolls ___________ Life/Medical/Insurance Premiums ___________ Deductible – Family or Single ___________ Doctor Visits (monthly average) ___________ Dentist and Vision ___________ Medications (monthly average) ___________ Clothing (monthly average) ___________ Laundry/Dry Cleaning ___________ Barber/Beauty/Nail/Tanning ___________ Newspaper/Magazine ___________ Child Support (Paid Directly) ___________ Children’s Allowances/Child Care ___________ Book Rental/Tuition/Books ___________ Yard Care/Pet Expense ___________ Fed/State Taxes (Paid Directly) ___________ Jewelry/Furniture/Appliance Rentals ___________ Entertainment: Internet ___________ Cable/Satellite ___________ Movies/Concerts/Movie Rental ___________ Health Club ___________ Clubs/Hobbies/Lessons ___________ Sports-Bowling/Golf/Basketball etc ___________ Lottery/Bingo/Gambling ___________ Dining Out/Fast Food ___________ Pool Supplies/Security System ___________ Trips/Vacations ___________ Tobacco ___________ Gifts: Birthday ___________ Christmas ___________ Holiday/Special Occasions ___________ Church/Charity ___________ School Loans ___________ Secured Loans ___________ Savings: Regular/Emergency ___________ Total Monthly Expenses ___________ Income Net Income Other Income Net Income Other Income #1 _________ #1 _________ #2 _________ #2 _________
Total Income Less Living Expenses Available Less Unsecured Debt Available (+ or -)
__________ __________ __________ __________ __________
Action Steps
1. $80.00 start-up fee by money order, is due by the 10th of the month that you start the DMP program. 2. CCCS payment by money order is $_______, this is due by the 20th of each month. 3. Review your statements each month. 4. Send in copies of your statements every 3 months. 5. Move your due dates to the last day of the month on credit cards. 6. Send copies of enrollment letters (takes up 90 days to accept) 7. With one missed payment a creditor may remove you from the program. Gross Income 1. ______________ 2. ______________ ______________ Total Gross Income ______________
Yearly Gross Income 1. ______________ 2. ______________ ______________ Total Yearly Gross Income ______________
Comments
THIS MUST BE COMPLETED BEFORE APPOINTMENT DATE
CHARGE CARDS, MEDICAL BILLS & UNSECURED LOANS
CREDITOR, ADDRESS, ZIP
1
OFFICE OFFICE USE ONLY USE ONLY
TELEPHONE NUMBER
ACCOUNT NUMBER
STATEMENT APR
CURRENT SCHEDULE CCCS PAY CCCS ARP PAY BALANCE
2
3
4
5
6
7
8
9
10
APPROXIMATE NUMBER OF MONTHS UNTIL PAYOFF
TOTAL
TOTAL
TOTAL
THIS MUST BE COMPLETED BEFORE APPOINTMENT DATE
CHARGE CARDS, MEDICAL BILLS & UNSECURED LOANS
CREDITOR, ADDRESS, ZIP
11
OFFICE OFFICE USE ONLY USE ONLY
TELEPHONE NUMBER
ACCOUNT NUMBER
STATEMENT APR
CURRENT SCHEDULE CCCS PAY CCCS ARP PAY BALANCE
12
13
14
15
16
17
18
19
20
APPROXIMATE NUMBER OF MONTHS UNTIL PAYOFF
TOTAL
TOTAL
TOTAL