Client Info Sheet

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CCCS of Buffalo- Client Information Sheet
Financial Counseling Application- 2016
APP LICANT 1
MAIDEN NAME:
FIRST
MI
LAST
<pick one>
SOC IAL SECURITY NUMBER: DA TE OF BIRTH:
GENDER:
<pick one>
DATE OF BIRTH: (MM/DD/YYYY)
EDUCATION:
<pick one>
<pick one>
ETHNICITY:
M ARITAL STATUS:
EM PLOYMENT STATUS:
<Pick one>
NUMBER IN HOUSEHOLD:
$ 0
Mo nthly Gross Pay (Before Taxes/Deductions):
$ 0
Monthly Net Pay (Take Home):
$ 0
Ad ditional Monthly Income(s): Amount:
Source:
$ 0
Amount:
Source:
APP LICANT 2
MAIDEN NAME:
MI
FIRST
LAST
<pick one>
SOC IAL SECURITY NUMBER: DA TE OF BIRTH:
GENDER:
<pick one>
DATE OF BIRTH: (MM/DD/YYYY)
EDUCATION:
EM PLOYMENT STATUS:
ETHNICITY:
<pick one>
<pick one>
$ 0
Mo nthly Gross Pay (Before Taxes/Deductions):
$ 0
Monthly Net Pay (Take Home):
$ 0
Source:
Ad ditional Monthly Income(s): Amount:
$ 0
Source:
Amount:
Contact by email ok: Yes
E-MAIL:
No
Addressing Your Financial Concerns:
Your appointment will be a professional review of your debt solution options. It is true that choosing an
appropriate debt option is important in creating your financial plan; but understanding your GOALS and
CONCERNS are as important, if not more important when it comes to putting together a game plan for your
financial future.
Your Counselor needs to know:
Future Financial Goals:
Financial Concerns:
1.
1.
2.
2.
3.
3.

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