| Your Name and Phone or Email: |
| Net monthly income/applicant: $ | Co-applicant income: $ |
| Mortgage payment: $ | Mortgage lender name: |
| Second mortgage payment: $ | Second mortgage lender name: |
| Car/Truck payment: $ | Car/Truck payment: $ |
| Student Loan(s): $ | Boat/Recreation Vehicle: $ |
| Rent: $ (if applicable): $ | Utilities (electric, gas, propane, trash, water, sewer): $ |
| Phone (land line): $ | Cell Phone: $ |
| Monthly Auto/Truck Insurance: $ | Monthly Auto/Truck Gasoline: $ |
| Monthly Food/household items: $ | Health, life, dental, vision: $ |
| Cash contributions: $ | Entertainment: $ |
| Cable/Satellite/Internet: $ | Clothing: $ |
| List and other monthly fixed costs not listed above: | |
| CREDITOR/Amount Owed | CREDITOR/Amount Owed |
Please provide us with a list of your Unsecured Debt Creditors: (No personal information or credit card numbers please
| Creditor | Balance Owed | Months late | Monthly Payment |
| $ | $ | ||
| $ | $ | ||
| $ | $ | ||
| $ | $ | ||
| $ | $ | ||
| $ | $ | ||
| $ | $ |
Once you have completed this information, put you name on it and fax it to us at 480-374-5287 or e-mail it to us at info@nationwidedr.com. One of our professional debt consultants will contact you and go over all of your options with you. By the way, congratulations for taking the challenge and for your commitment to do something about your debt!