CREDIT SOLUTION CENTRE

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Assessment
CREDIT SOLUTION CENTRE
CLIENT ASSESSMENT FORM


This form is for potential clients to easily forward information to our offices and request an appointment.

    * What caused you to contact us? (check all that apply)
            Accident or Illness
            Divorce or Separation        
            Garnishee of Pay                           
            Repossession
            Collection Agencies Harassing
            Reduced Income or Job Loss
            Mortgage Foreclosed
        * Other reasons:
            
   
    * What bills do you have? (check all that apply)
            Credit Cards
            Taxes
            Personal Loans
            Payday Loans
            Child or Spousal Support
            Mortgage
            Student Loans
    * Other bills:
                
        * How much do you owe in total?
            $ 
  

    * Tell us about the assets you own:
           I own real estate.
           My mortgage payments in arrears.
           I own a car or truck.
           My car/truck payments in arrears.
           I have RRSP's.
           I have investments.
    * Describe any other significant assets:
              


    * Income
            None
            Full-time Job
            Part-Time Job
            Retirement Pension
            Child or Spousal Support
            Social Assistance or Welfare
    * Other Income:
            
    * Estimate total monthly net income:
            $ 
    

    * Family
            Single
            Married
            Common-Law
            Separated
            Divorced
            Widowed
    * Number of people in your family (including you):
           
    *
    

    *Contact Information
    * First Name    

       Last Name   
   
   How would you like us to contact you?
    * Phone - () -  -

       Email -
    *
    Address
      Street Address
     
      City
      
       Prov.                            Postal Code
                                
      
    * Your Question/Message?
       

    * I agree to the Terms & Conditions                    
     

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