CCCS Application

Consumer Credit Counseling Service of Oklahoma
You may complete this application and submit it on-line right to our email, or print out the form, complete it,
and fax it to us at (918) 744-0232.

Applicant Information

Last Name:

First Name:

Middle Name:

Date of Birth:

Present Address:

City:

State:

Zip Code:

Home Phone:

Employer:

Employer Address:

Length of Time Employed:

Work Phone:

Driver's License #:

Vehicle

Year:

Make:

Own: Buying:

Spouse's Information

Last Name:

First Name:

Middle Name:

Date of Birth:

Employer:

Employer's Address:

Length of Time Employed:

Work Phone:

Driver's License #:

Vehicle

Year:

Make:

Own: Buying:

Number of Children:

Ages:

What is the besst time for us to reach you?

What number should we call? (area code first)

E-mail:

Income

Client's Payday(s): Gross Pay Check:

Take Home/Payday: Monthly Take Home:

Spouse's Payday(s): Gross Pay Check:

Take Home/Payday: Monthly Take Home:

Other Income

Child Support: Part Time:

Social Security: Other:

Total Take Home Income:

Family Expense Per Month (To be Completed by Prospective Client)	Monthly Expenses	Counselor Suggested Expenses
Rent
Mortgage
Electric
Gas/Heating
Water
Telephone/Pager/Cell Phone
Food
Auto (Gas, Repairs, etc.)
Automobile Payments
Ongoing Medical (Doctors, Prescriptions)
Insurance (Car, Life, Health, Etc.
Child Care
Alimony/Child Support
Secured Debt on DMP
Secured Debt not on DMP
Tax Payments
Contributions
School Expenses
Miscellaneous
Total Expenses

Please list all your outstanding debt including car payments, retail and charge card accounts, credit union loans,
bank loans, delinquent taxes, family/personal loans, student loans, etc. Please list those accounts that are deducted
from your payroll or bank account. It is important to list all debts, whether your account is current or past due.
Fax your most current statements.

Name of Creditor/Address	Telephone Number	Balance	Monthly Payment	# Months Delinquent