Welcome to Community Credit Counseling Corp.

We are a non-profit 501(c)(3) accredited organization that offers real solutions to becoming debt free. We are dedicated to educating and helping people become financially independent today, tomorrow and well into the future. Just simply complete and submit this secured form for an analysis of your debt. We offer this service for free. No Cost or Obligation to you. Our toll free number is 1-877-BILLS-11 and our website is www.commcredit.org.

CREDITOR LISTING SHEET CCCCCLFS Revision A 10/21/2014

Today,s Date * +

How Did You Hear About Us

Email Address *

First Name * 🛈

Last Name *

State *

Contact Phone # *

Best Time to Call

Creditor 1

Creditor's Name *

Account # (optional) 🛈

Current Balance *

Monthly Payment *

Int. Rate % *

# of Pymts. Behind *

Day of Month Payment Due *

Name of Primary if Different

If this acct. is with a collection agency, please provide address and telephone #

Creditor 2

Creditor's Name

Account # (optional) 🛈

Current Balance

Monthly Payment

Int. Rate %

# of Pymts. Behind

Day of Month Payment Due

Name of Primary if Different

If this acct. is with a collection agency, please provide address and telephone #

Creditor 3

Creditor's Name

Account # (optional) 🛈

Current Balance

Monthly Payment

Int. Rate %

# of Pymts. Behind

Day of Month Payment Due

Name of Primary if Different

If this acct. is with a collection agency, please provide address and telephone #

Creditor 4

Creditor's Name

Account # (optional) 🛈

Current Balance

Monthly Payment

Int. Rate %

# of Pymts. Behind

Day of Month Payment Due

Name of Primary if Different

If this acct. is with a collection agency, please provide address and telephone #

Creditor 5

Creditor's Name

Account # (optional) 🛈

Current Balance

Monthly Payment

Int. Rate %

# of Pymts. Behind

Day of Month Payment Due

Name of Primary if Different

If this acct. is with a collection agency, please provide address and telephone #

Do you have more Creditors to add? *

Yes