Debt Settlement Application

Please complete the application form below to start a Debt Reduction program file. There are no upfront costs to apply for these services. Our legal network help you to discover the best solution to achieve financial wellness. Your information is secure and will not be used for any purpose other than preparing a file for our firm to utilize. Leave blank any line items that you are not sure how to answer. Note: Your promptness is greatly appreciated. We would like to process your file as quickly as possible. In order to do this all requested documentation and information must be completed in full prior to the file being sent to our law firm.

Please call (209) 642-0512 if you have any questions. You may fax your documents to (209) 370-8467 or email to: info@netfactorsfws.com

APPLICATION FOR DEBT SETTLEMENT

APPLICANT CO-APPLICANT

Full Name

Current Address

City

State

Zip Code

Home Phone

Work Phone

Cell Phone

Fax

Social Security Number

Birth Date

Marital Status

CREDITORS

Creditor Name / Original Creditor

Accnt Last 4

Monthly Pmt

Balance Due

Debt Type

$ Past Due

10.

13.

14.

15.

Please provide copies of credit statements or a credit report. We can help you to obtain these documents.

BUDGET

INCOME	BASIC EXPENSES	OTHER EXPENSES
Applicant Net Salary	Rent	1st Car Pmt	Dining Out
Co-Applicant Net Salary	Mortgage	2nd Car Pmt	Sports & Hobbies
Retirement/Pension	2nd Mortgage	Car Maintenance	Magazines
Child Support	Property Tax	Gasoline	Dry Cleaning
Social Security	Home Maintenance	Car Insurance	Health Club
Disability	Home Insurance	Health Insurance	Hair & Nails
Gov Grant	Gas & Electric	Health Expenses	Pet Expenses
Other Income	Water/Trash/Sewer	Life Insurance	TV & Internet
	Telephone/Cell	Monthly Child Support	Other Expenses
	Grocery	Monthly Child Daycare
	Clothing & Shoes	Credit Cards


			TOTAL EXPENSES

EMPLOYMENT

APPLICANT

CO-APPLICANT

Employer Name

Length of Employment

GROSS INCOME

NET INCOME (after tax)

BANK INFO

Name of Financial Institution or Bank Name

Routing #

Account #

Preferred Monthly Date of Draft

Note: This does not authorize a draft. Contract must be signed fist

ASSETS

Home Value

Mortgage Balance

1st Automobile Value

2nd Automobile Value

3rd Automobile Value

Other Vehicle Value

Checking Account

Savings Account

Interest General

Life Insurance

Stocks & Bonds

401K

Annuities

Other

SELECT A HARDSHIP

PLEASE PROVIDE A BRIEF HARDSHIP EXPLANATION

Unemployment – Reduced Income – Job Relocation – Medical Bills – Death in Family – Payment Increase – Military Service – Damage to Property – Adjustable Rate Mortgage – Business Failure – Incarceration – Illness – Divorce/Separation