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How did you learn about Robert Weinberg?:

The things I most want Robert Weinberg to do for me are:

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I am in "credit counseling."

General Info:

Full Name: Date of Birth:

Spouse Full Name: Date of Birth:

E-mail address:

Home phone number: I'm at home:

Work phone number: I'm at work

Home address:

Street:

City: State: ZIP:

I have rental income property


Time in Home:

I lived in my home (years):

Purchase price: $



Assets:

My Home's Value: $

Checking and Savings Accounts: $

Other Non-Retirement Investment Accounts: $

401K and Other Retirement Accts: $

Other Assets $



My Debts:

Total # of Credit Cards with Balances

Total Balance on All Credit Cards

Total Minimum Monthly Payments on All Credit Cards

Total Other Consumer Debt Balances

Total Other Consumer Debt Payments


Credit Card 1: $ Rate Min Pmt

Credit Card 2: $ Rate Min Pmt

Credit Card 3: $Rate Min Pmt

Credit Card 4: $ Rate Min Pmt

Credit Card 5: $ Rate Min Pmt

Credit Card 6: $ Rate Min Pmt

Credit Card 7: $ Rate Min Pmt

Credit Card 8: $ Rate Min Pmt

Credit Card 9: $ Rate Min Pmt

Credit Card 10 $ Rate Min Pmt

Other Debt 1: $ Rate Min Pmt

Other Debt 2: $ Rate Min Pmt

Other Debt 3: $ Rate Min Pmt

Other Debt 4: $ Rate Min Pmt

Other Debt 5: $ Rate Min Pmt

Other Debt 6: $ Rate Min Pmt

Other Debt 7: $ Rate Min Pmt

Other Debt 8: $ Rate Min Pmt

1st Mortgage: $ Rate Min Pmt

2nd Mortgage: $ Rate Min Pmt



Property Taxes:

ANNUAL amount of property taxes?: $

Taxes are: Included in mortgage Not included in mortgage



Homeowners' Insurance:

Insurance is Included in mortgage. Not included in mortgage.

Insurance is $ per YEAR.



Other Monthly Living Expenses:

Other monthly living expenses $ per month.



Income:

Your Employment

My income before taxes is: $

Time on job: years, months

Job title:

Employer name:


Your Spouse:

Spouses income before taxes: $

Time on job: years, months

Job title:

Employer name:





I will contact you within 24 business hours of submission. I will have your 'Cost Savings Analysis' ready for you! Thank you!

Sincerely,

Robert Weinberg
Debt Elimination Expert