How much debt do you have?

Do you have difficulty making monthly payments?

Yes
No

Are you able to pay more than the minimum monthly payment?

Yes
No

Have you ever been late on a payment?

Yes
No

What type of debt do you have (check all that apply)?

Credit Cards
Student Loans
Mortgages
Auto Loans
Other

What is your yearly family income?

Do you have daily worries about your bills?

Yes
No

Do you feel like there’s no solution to your financial problems?

Yes
No

Please describe your situation:

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