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You can use this form to submit your online telephone debt analysis. Simply fill in the form below and click SEND.

"*" indicates required fields

Your Name*

Spouse's Name

County of Residence*

Email*

Phone*

Approximate Total Amount of Credit Card Debt

Approximate Total Amount of Medical Debt

Approximate Total Amount of Unsecured Loans (Finance Company or Bank Signature Loans)

Approximate Total Amount of UnsecureApproximate Total Amount of Past Due Taxes

Are the debts in both spouses' names?

Yes

Do you own a home?

Yes

Approximate market value of home

Tax value of home

1st mortgage balance due on home

2nd mortgage balance due on home

Approximate value of 1st automobile

Amount owed on 1st automobile

Approximate value of 2nd automobile

Amount owed on 2nd automobile

Approximate monthly income

Spouse's approximate monthly income

May we email you back confidentially?

Yes

May we call you at the number above?

Yes

Best time to call

Comments

Phone

This field is for validation purposes and should be left unchanged.

OFFICES AT LAKE PARK
1420 Old Lenoir Road, Suite D
Hickory, NC 28601