Debt Consolidation Quote Request (non-homeowners only)

You must complete this entire form in order to 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. ** YOU MUST HAVE AT LEAST $4,000 IN DEBT TO APPLY ** 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. First name: Last name: Address: City: State: Select Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware District of Columbia Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan CURRENTLY NOT ACCEPTED Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming Zip: Home Phone: Work Phone: Pager / Cell (If applicable): Email: How many creditors? 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 33 34 35 36 37 38 39 40 41 42 43 44 45 46 47 48 49 50 ** 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: 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: Debt-Consolidation-Loans-Online is not a credit counseling agency, and refers non-homeowner applications to an independent agency which specializes in this area. By completing this application, applicant promises to hold harmless Debt-Consolidation-Loans-Online 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. Debt Consolidation Loans Online, Tel: 800-996-2698 © Copyright 2000 Debt Consolidation Online. Unauthorized use strictly forbidden.