Credit Assistance Application Form

CREDIT ASSISTANCE APPLICATION FORM

This Credit Assistance Application is submitted to request evaluation for credit counseling, loan modification, debt consolidation, or other credit assistance services. Completion of this form authorizes the recipient to verify the information provided, obtain consumer credit reports, and communicate with listed creditors as necessary to evaluate and administer requested assistance. All fields must be completed accurately; false statements may affect eligibility and may be subject to penalties under applicable law.

Applicant Information

Co-Applicant (if applicable)

Employment and Income

Assets & Liabilities Summary

Current Creditors (List most significant accounts)

Provide account information for current unsecured and secured creditors. Attach additional pages if necessary.

Requested Assistance

Select the type(s) of assistance requested. Check all that apply and provide requested amounts or terms.

Documentation & Verification

I understand that supporting documentation is required to verify income, assets, and liabilities. Requested documents may include identification, pay stubs, bank statements, tax returns, bills and creditor statements. Failure to provide requested documentation may result in denial of assistance.

Authorizations, Certifications, and Acknowledgements

By submitting this application I authorize the recipient and its agents to obtain and review consumer credit reports, employment and income verifications, and to contact creditors and other third parties as necessary to evaluate and administer requested services. I authorize any current or former employer, financial institution, creditor, landlord, or governmental agency to release information necessary to verify statements made in this application.

I certify under penalty of perjury that the information provided in this application and any accompanying documentation is true, complete, and correct to the best of my knowledge. I understand that intentional misrepresentation or omission of material facts may result in denial of assistance and may be actionable under civil or criminal law.

I acknowledge that submission of this application does not constitute approval for assistance. Any offer of assistance will be evidenced by a separate agreement setting forth specific terms, fees if applicable, repayment obligations and default remedies. I agree to receive communications related to this application by telephone, mail, email, or electronic message at the contact information provided.

Privacy Notice

Personal information provided on this application will be used solely for the purpose of evaluating eligibility for credit assistance and related administrative purposes. Information will be disclosed only as necessary to verify information, obtain credit reports, or as required by law. The applicant retains the right to request access to information provided and to correct factual inaccuracies.

Certification

I, the undersigned applicant, certify that I have read and understood this application and that the statements made herein are true and complete. I authorize verification and release of information as described above and acknowledge that any assistance provided will be subject to separate written terms and conditions.

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