Mystar Credit Counseling

Why Choose Mystar? Debt Quiz Home

Debt Management Program Application

For a FREE evaluation on whether a Debt Management Plan is right for you please
fill out the following fields and you will be contact usually within 24 hours. All information
is confidential and you are under No Obligation. It's your debt, your choice and your financial future.

Immediate Phone Consultation Available M-F 8:00am - 5:30pm and Saturday 8:00am-Noon

Name:

Spouse:

Address:

Email:

City:

State:

Zip:

Home Phone:

Cell:

Employer 1:

Primary Phone:

Employer 2:

Secondary Phone:

Monthly take home pay:

Other income:

Spouse's monthly take home pay:

...........................................................................................................................................................

Living Expenses:


Rent/Mortgage:				Groceries
Electricity:				Heat:
Water:				Cable:
Telephone:				Car Insurance:
Car Payment #1:				Car Payment #2:
Other:

...........................................................................................................................................................

Client Debt Information
Fill in the Debt List using the information from your MOST CURRENT statements.


Account Name (including mortgage & car loans)	Monthly Payment	Last Time Paid	Current Balance	Interest Rate
(example) Chase Visa		July 2007	$1,260.00	19%

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Main Office: 7271 N. Shadeland Avenue • Indianapolis, IN 46250

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