Do you own, or are you purchasing any vehicles?  Yes    No

If you answered "Yes" above complete the following information:

Vehicle 1 , ,

Fair Market Value $        Balance Owed $

Monthly Payment $

Are you behind on this vehicle? Choose one Yes No

If yes, how much are you behind?

What are your intentions with this vehicle? Choose one Retain Surrender

Vehicle 2 , ,

Fair Market Value $        Balance Owed $

Monthly Payment $

Are you behind on this vehicle? Choose one Yes No

If yes, how much are you behind?

What are your intentions with this vehicle? Choose one Retain Surrender

Vehicle 3 , ,

Fair Market Value $        Balance Owed $

Monthly Payment $

Are you behind on this vehicle? Choose one Yes No

If yes, how much are you behind?

What are your intentions with this vehicle? Choose one Retain Surrender