Detailed Application

Contact Info
First Name *
Last Name *
Employer
Spouse
Total Number of People in family/household *
Number of Dependant Children *
Address *
City *
Province *
Postal Code *
Home Telephone *
Cell Phone
Preferred Phone *
Best Time to Call *
Best Call Day/Time
E-Mail *
Confirm E-Mail
How did you find out about us?

Current Situation

How much UNSECURED Debt do you have? *

Types Of Debt - please check all that apply *

Credit Card
Finance Company Loans
Line Of Credit
Bank Overdraft
Personal Loans

Overdue Rent or Utilities
Student Loans
Government Debt
Secured
Other

Are any of your debts joint or co-signed? *	Yes No
Have you been turned down for a loan? *	Yes No
Are you interested in consolidating debts into one monthly payment? *	Yes No
Are you receiving collection calls? *	Yes No
Are your payments up-to-date? *	Yes No
Are you receiving income? *	Yes No
Do you have an account in a bank to whom you do not owe any money? *	Yes No
Add me to your mailing list?	Yes No

Comments: What would you like us to help you with?

Income
Please enter current estimated MONTHLY dollar amounts.
	Monthly Notes & Comments
Net Income (self) *	$
Net Income (spouse)	$
Child Tax Credit	$


	Monthly Notes & Comments
GST (monthly)	$
Rental Income	$
Pensions	$
Interest & Dividends Earned	$
Other Income	$

Monthly Expenses

HOUSING Expenses	Monthly
1st Mortgage PI/PIT	$
2nd Mortgage	$
Rent/Condo Fees	$
Property Taxes	$
Electricity	$
Heating Oil/Natural Gas	$
Water/Sewer	$
House Insurance	$
Cable TV	$
Telephone	$
Cell Phone	$
Internet/Home Security	$
Other:	$

More Information about Expenses Please add any notes or comments here.


WORK Expenses	Monthly
Transit/Taxies/Parking	$
Lunch/Breaks	$
Daycare	$
Other:	$

LIVING Expenses	Monthly
Food & Groceries	$
Gas & Oil	$
Auto Repair/Tune-ups	$
Insurance - Auto	$
Insurance - Life	$
Clothing	$
Alimony & Support Payments	$
Medical/Doctor	$
Dental	$
Prescription Drugs	$
Laundry/Dry Cleaning	$
Personal Grooming/Hygiene	$
Other:	$

DISCRETIONARY Expenses	Monthly
Recreation/Entertainment	$
Tobacco	$
Alcohol/Beverages	$
Allowances	$
Charitable Donations	$
Monthly Savings	$
Other:	$

MANDATORY Expenses	Monthly
Car Payment	$
Debt Payments on Credit Cards	$
Other:	$
Other:	$

MISCELLANEOUS Expenses	Monthly
Other:	$
Other:	$

Assets

Savings/Cash on hand* $

Home Contents Value $

RRSPs & Investments $

Other Assets $

Major Assets and Secured Creditors

Home Value $ Type of building

1st Mortgagor name Owing $ at %, pymt $ Notes:

2nd Mortgagor name Owing $ at %, pymt $ Notes:

Vehicle 1 Value $ Year, Make & Model

Sec Creditor name Owing $ at %, pymt $ Notes:

Vehicle 2 Value $ Year, Make & Model

Sec Creditor name Owing $ at %, pymt $ Notes:

Boat / RV Value $ Year, Make & Model

Sec Creditor name Owing $ at %, pymt $ Notes:

Unsecured Creditors

Creditor 1 name* Owing $ at %, min pymt $ Notes:

Creditor 2 name Owing $ at %, min pymt $ Notes:

Creditor 3 name Owing $ at %, min pymt $ Notes:

Creditor 4 name Owing $ at %, min pymt $ Notes:

Creditor 5 name Owing $ at %, min pymt $ Notes:

Creditor 6 name Owing $ at %, min pymt $ Notes:

Creditor 7 name Owing $ at %, min pymt $ Notes:

Creditor 8 name Owing $ at %, min pymt $ Notes:

Creditor 9 name Owing $ at %, min pymt $ Notes:

Creditor 10 name Owing $ at %, min pymt $ Notes:

Creditor 11 name Owing $ at %, min pymt $ Notes:

Creditor 12 name Owing $ at %, min pymt $ Notes:

Creditor 13 name Owing $ at %, min pymt $ Notes:

Terms*: I have reviewed the frequently asked questions page and agree to the terms and conditions below.

This application does not obligate you in any way to purchase any products or services.
The privacy of the personal information you have provided will be carefully protected.
Your contact information will not be sold, rented or distributed in any form.
It is for the sole express purpose of allowing us to send you information about our products and services.

AA Credit Counsellors