Congratulations! Your decision to take the first step by enrolling in the Christian Credit Counselors Debt Management Program ensures that you are on the road to financial freedom. To learn how much you can save, please fill in the simple, no obligation form.

A CCC Certified Credit Counselor will contact you within 24 hours (8am-6pm EST Mon.-Fri.) All information is handled confidentially.



Please fill in the form to the best of your ability. All fields marked with a (*) are required.

*Your Email Address:
*Your Full Name:
Spouse's Full Name:
Street:
City:
State:	AL AK AR AZ CA CO CT DC DE FL GA HI ID IL IN IA KS KY LA ME MD MA MI MN MS MO MT NE NV NH NJ NM NY NC ND OH OK OR PA RI SC SD TN TX UT VT VA WA WV WI WY DC PR Zip:
*Primary Phone Number:
Alternate Phone:
Fax Number:
Best Contact Time:	Daytime Evening
How did you hear of us?	Television Ad Newspaper Ad Magazine Ad Radio Ad Internet Search Agency Referral Friend or Family

Your Income

Monthly Take Home Pay:
Spouse's Take Home Pay:
Other Income Amount:
Your Current Employer:

Your Expenses

Tithes/Charity: Rent/Mortgage: Lot Rent: Property Tax: Insurance: Electric: Water/Sewer: Gas:

Phone: Cable/Internet: Food: Auto 1: Auto 2: Fuel: Auto Insurance: Child Care/Tuition: Other Expenses:

Debt Summary

Please fill in the Debt Summary using information from your most Current Statements. Our counselors work with all credit cards, department stores, gas cards, and other unsecured debts.

Creditor Name	Debt Type	Current Balance	APR%	Amount Owed	Minimum Payment

Additional Information

(Please let us know if any urgent information, such as anticipated changes in income or expenses.)

Debt Management Agreement*

Please download our Debt Management Agreement form. This agreement states that Christian Credit Counselors (CCC) will act as an agent on your behalf for arranging and making payments to your creditors. Simply download the file and return it to us. This form is required before any work can begin. Download Now »


Payroll Deduction / Account Withdrawal Authorization*

Please download our Payroll Deduction / Account With drawl Authorization form. For your convenience, Christian Credit Counselors offers either Payroll Deduction or Account Withdrawal payment options. Through our automatic deduction service, you can make one payment per month or you can have your payment coincide with your payroll deposits. Download Now »


Printable Application

Please download our Printable Application form. For your convenience, Christian Credit Counselors has made the preceding application form available for download. If you prefer a printable version of the application, simply download it here and return to us with along with the required Supplemental Downloads. Download Now »


*Indicates forms or information which is required before work can begin. All downloads are available in Adobe Acrobat® (.pdf). Don't have Acrobat? Download Here »
If you have any questions, please Contact Us.