Budget Counseling Worksheet

Today is the first day of the rest of your life. Are you in control of your credit?

Please provide the following confidential information. Upon receipt of your form, a counselor will contact you to set up an appointment.

Your Name:	Your Gender:
Street Address:
Address (cont.):	(use second line for Apartment Number, Box Number, etc.)
City:
State:	Postal/ZIP Code:
Work Phone:
Home Phone:
E-Mail Address:

Please list any minor children or others legally dependent upon you and their ages:
(example: Bobby Doe, 9 years; Susie Doe, 3 years; Mary Doe, 1 year;)

Do you: rent own

Is this regarding: budgeting bankruptcy credit card debt other, please explain below:

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Budget Counseling Worksheet