Debt Consolidation Loan Non Homeowner

Completing this form in its entirety will ensure a response. Within a few days, a representative will contact you with a free quote. This quote will consist of a new monthly payment, a new interest rate and a new term to get out of debt. Debt Consolidation & Second Mortgage Center is not a credit counseling agency, and refers non-homeowner applications to a independent credit counseling agency which specializes in this area. By completing this application, applicant promises to hold harmless Debt Consolidation & Second Mortgage Center or any of its owned related companies from any and all actions, errors or legal actions that may arise from the company it is referred to.

** YOU MUST HAVE AT LEAST $4,000 IN DEBT TO APPLY
** Sorry, NO AUTO or SCHOOL LOANS.

Before you continue please have the following information available:

Creditor Names
Current Balance
Monthly Payment
# of Months Behind
Purpose of Debt

This information will enable us to expedite the processing of your creditor listing form.
Please complete all * fields.

*First: Name
*Last Name:
*Address:
*City:
*State:	All States Except Michigan
*Zip:
Home Phone:	-
*Work Phone:	-
Pager / Cell (If applicable):
*Email:	(cannot process without email)
*How many creditors?

** IMPORTANT**

ALL of the following MUST be included in order to be referred for a quote. Please list all of the following for EACH account in the space below (there is room for 10 creditors):

1. Creditor Name
2. Current Balance
3. Monthly Payment
4. # of Months Behind
5. Purpose Of Debt
Please list creditors here(Sorry, NO AUTO or SCHOOL LOANS):
Important: application will be considered invalid if not completed properly.

CREDITOR NAME #1: CURRENT BALANCE: MONTHLY PAYMENT: # OF MONTHS BEHIND: PURPOSE OF DEBT: CREDITOR NAME #2: CURRENT BALANCE: MONTHLY PAYMENT: # OF MONTHS BEHIND: PURPOSE OF DEBT: CREDITOR NAME #3: CURRENT BALANCE: MONTHLY PAYMENT: # OF MONTHS BEHIND: PURPOSE OF DEBT: CREDITOR NAME #4: CURRENT BALANCE: MONTHLY PAYMENT: # OF MONTHS BEHIND: PURPOSE OF DEBT: CREDITOR NAME #5: CURRENT BALANCE: MONTHLY PAYMENT: # OF MONTHS BEHIND: PURPOSE OF DEBT: CREDITOR NAME #6: CURRENT BALANCE: MONTHLY PAYMENT: # OF MONTHS BEHIND: PURPOSE OF DEBT: CREDITOR NAME #7: CURRENT BALANCE: MONTHLY PAYMENT: # OF MONTHS BEHIND: PURPOSE OF DEBT: CREDITOR NAME #8: CURRENT BALANCE: MONTHLY PAYMENT: # OF MONTHS BEHIND: PURPOSE OF DEBT: CREDITOR NAME #9: CURRENT BALANCE: MONTHLY PAYMENT: # OF MONTHS BEHIND: PURPOSE OF DEBT: CREDITOR NAME #10: CURRENT BALANCE: MONTHLY PAYMENT: # OF MONTHS BEHIND: PURPOSE OF DEBT:

� Copyright 2000-2001 Debt Consolidation & Second Mortgage Center.
Unauthorized use strictly forbidden.