Name
Address
City
State
Zip
Home Phone
Work Phone
E-Mail

Home Owner

Select Yes No

.

Please be sure to enter your complete e-mail address. A proper e-mail address should contain your name, an @ and name of domain. For example- info@myplace.net, help@aol.com, sally@yourdomain.net etc.

End of Part 1. Complete part 2 before submitting.

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Bookmark this page! AOL members, make this your favorite place.

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You may wish to gather all your bills at this point. Please list unsecured debts (credit cards, medical bills, personal signature loans from accredited lending companies, old utility bills, back taxes etc.) Do not list secured debts such as car payments (repo's ok) or mortgages, current utilities, court ordered payments like alimony or child support. When listing creditors make sure you list each individual creditor ex. City Bank Visa or Wells Fargo Mastercard not just Visa or Master Card. When listing medical bills list each individual doctor, clinic or hospital.

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Creditor
Amount Owed
Monthly Payment
Months Behind
Purpose of Debt

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Creditor
Amount Owed
Monthly Payment
Months Behind
Purpose of Debt

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Creditor
Amount Owed
Monthly Payment
Months Behind
Purpose of Debt

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Creditor
Amount Owed
Monthly Payment
Months Behind
Purpose of Debt

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Creditor
Amount Owed
Monthly Payment
Months Behind
Purpose of Debt

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Creditor
Amount Owed
Monthly Payment
Months Behind
Purpose of Debt

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Creditor
Amount Owed
Monthly Payment
Months Behind
Purpose of Debt

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Creditor
Amount Owed
Monthly Payment
Months Behind
Purpose of Debt

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Creditor
Amount Owed
Monthly Payment
Months Behind
Purpose of Debt

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Creditor
Amount Owed
Monthly Payment
Months Behind
Purpose of Debt

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If you have additional bills, submit the current application and then resubmit the rest. Be sure to include your name on any additional submissions.

Please submit each list of creditors one time only. It may take a few moments to transmit so please be patient.

Use the email option only if absolutely necessary. Our estimated 24-48 hour response time based on submission by online application only.

Please, serious inquiries only. Incomplete or frivolous applications will be discarded. This form is for those who are serious about handling their bills in a responsible manner.

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