Credit Cards        $                                                            Bounced Checks        $

Medical Bills        $                                                            Payday Loans            $

Back Taxes          $                                                            Student Loans           $

Repossession       $                                                            Signature Loans        $
                                                                                                                        (loans with no collateral)
Back Child            $                                                            Other  Please describe 
     Support

How much debt do you have not counting vehicles or mortgages?  Please describe

How many creditors do you believe you have?  Please describe

If you have credit card debt, when was the last time you charged?  If it was within the last 90 days, please list amounts and types of purchases