Consumer Credit Counseling's

On Line Application Form


bullet10.gif (1099 bytes)National Non Profit Consumer Credit Counseling Agency

TOLL FREE: (877) 426-6363
info@4-consumercredit.com

On Line Application


Your New Monthly Payment will be returned to you within "1" hour! 

Complete this form, then use the "Submit Now" button to E-mail the Application Form to ACC Credit Counseling.  Your personal information will be retrieved and reviewed by one of  our Counselors.  Your Counselor will then email you the results within "one hour"!

Confidential Budget Information

 PERSONAL DATA
Complete as"John Smith" or "John and Mary Smith"  Maiden names are required if they are used on the accounts and must appear in parentheses as "Smith(Maiden name)".  Note that there are NO spaces between the Last and Maiden name with parentheses enclosing it. 

First and Last Name 
(1st Name listed) Suffix:
Jr: Sr: N/A: 		 D.O.B. (MMDDYY)
 S.S.N. (No Dashes)
 
(2nd Name listed) Suffix:
Jr: Sr: N/A: 		 D.O.B. (MMDDYY)
 S.S.N. (No Dashes)
Address
 Or P.O. Box
City
 State
 Zip Code
Time Zone                             Home Phone (No Dashes)
 Fax Number (No Dashes)
 E-Mail Address:
Single
 Married
 Separated
 Divorced
 Widowed

2. YOUR HOUSING
Are You: Renting:  Buying:  Own a Home:  Other: 
Regarding This Payment, Are You: Up to Date:  Past Due: 

3. INCOME               (DOES NOT AFFECT YOUR PAYMENT AMOUNT TO US IN ANYWAY)
(DO NOT SPEND A LOT OF TIME IN THIS SECTION, COMPLETE AS ACCURATELY AS POSSIBLE)
Your Employer
Job Title
Your Work Telephone Ext: 
Spouse's Employer
Job Title
Spouse's Work Telephone Ext: 
(3a) Your Gross Monthly Pay $
(3c) Take Home Pay $
(3d) Spouse's Gross Monthly Pay $
Take Home Pay $
(3e) Other Income $
TOTAL INCOME $

4. YOUR MONTHLY EXPENSES (DOES NOT AFFECT YOUR PAYMENT AMOUNT TO US IN ANYWAY)
(DO NOT SPEND A LOT OF TIME IN THIS SECTION, COMPLETE AS ACCURATELY AS POSSIBLE)
(4a) Housing $
(4b) Food $
(4c) Utilities $
(4d) Transportation $
(4e) Personal $
(4f) Family $
(4g) Entertainment $
(4h) Other $
TOTAL MONTHLY LIVING EXPENSES $

5. YOUR CREDITORS(PLEASE MAKE SURE YOUR INFORMATION IS ACCURATE!)
Creditor Account# (No Spaces or Dashes!) Current
Balance		 Monthly
Payment		 What is Debt for?   # of Pmts
 behind (if any)
1. $ $  
2. $ $  
3. $ $  
4. $ $  
5. $ $  
6. $ $  
7. $ $  
8. $ $  
9. $ $  
10. $ $  
11. $ $  
12. $ $  
13. $ $  
14. $ $  
15. $ $  
16. $ $  
17. $ $  
Desired monthly payment date (1-21st only) 
  What "Keywords" did you type to find our site?  
  Additional Comments:  
How did you learn about AMMEND?

By clicking on the Submit Now button, YOU UNDERSTAND:

ACC Credit Counseling, The National *Non Profit Consumer Credit Counseling Agency Community   Service Organization.

All ACC services are free to consumers. Funding comes primarily from creditors participating who are willing to make contributions to help fund ACC's counseling, debt management and education programs.

By clicking on the Submit Now button, YOU AUTHORIZE:

ACC Credit Counseling, including its employees, officers and agents to discuss any and all aspects of my financial affairs with whom they deem necessary in order to help me solve my financial problems. I agree to hold ACC harmless from any claim, suit, action or demand of my creditors, myself, or any other person arising out of this agreement.  Any of my creditors to discuss my account with ACC, which includes,

but is not limited to, balance information, payment history, and potential adjustments to contractual terms and conditions that the creditor may be willing to make.

info@4-consumercredit.com