Please print this entire document and complete the blank fields.
Congratulations!
You have taken an important step in addressing your financial concerns. Before you begin completing your Money Manager Planner, please note the following information.
Discussing one's personal finance is often difficult, stressful, and sometimes embarrassing. The counselor you will meet with is a professional who is dedicated to assisting you. All counseling sessions are private and are kept strictly confidential. Telephone Counseling is also available.
The key to a successful consultation is filling out the enclosed forms accurately and completely. Your counselor wil rely heavily on that information in making suggestions and recommendations. Incomplete or erroneous information may result in our being unable to properly advise you.
Please call for an appointment, and we would encourage you to bring your completed application with you to the appointment. Married couples are encouraged
to attend together. Most appointments last an hour and a half.
Please do not bring children with you. We look forward to working
with you.
CHECKLIST
__Three Recent Paycheck Stubs
__All Creditor Statements
__Completed Money Manager Planner
__Any Garnishment/Legal Documents
Appointment Date:____________
Appointment Time:____________
Location:___________________
Counselor:__________________
"Directions for Mastering Money Management"
Birmingham-Anniston-Hoover
Main Office
(205) 251-1572
Toll Free
1-888-260-CCCS
(2227)
| Name/Address/Phone |
| Last Name, First, Middle, Maiden | Date of Birth | Social Security Number |
| Spouse | Date of Birth | Social Security Number |
| Current Address
City State Zip |
How Long?
County |
Home Telephone
Rent Mortgage Other |
| Previous Address
City State Zip |
| Martial Status (cirle one):
Single Married Divorced
Widowed Number of Children in Household
Ages |
| Employer |
| Employer | Occupation |
| Address | Telephone |
| City State Zip | Length of Employment |
| Employer | Occupation |
| Address | Telephone |
| City State Zip | Length of Employment |
| Income |
| Self(circle one)
Weekly Biweekly Bimonthly Monthly |
Spouse(circle one)
Weekly Biweekly Bimonthly Monthly |
|
| Gross Income(1) | ||
| Take Home Pay | ||
| Payroll Deducted Loans/Allotment | ||
| Gross Income(2) Part Time Job | ||
| Take Home Pay | ||
| OTHER SOURCES INCOME (TAKE HOME) | Self | Spouse |
| Alimony / Child Support | ||
| Social Security / Retirement | ||
| Unemployment | ||
| Other |
| Have you ever filed for bankruptcy? Year: Chapter 13 Chapter 7 |
| For office use only:
Bottom Line
|
| Debt (Please bring copies of most recent creditor statements) |
| Creditor Name | Type of Mortgage | Date of Purchase | Payment | Interest | TOTAL BALANCE | Years Financed |
| Mortgae(List) | ||||||
| Automobile (List) | Year/Model | |||||
| Creditor (List) | Account Number | Secured With | Minimum
Payment |
Interest | Total Balance | DMP | Adjusted |
| Goals: |
|
|
| Housing | Monthly Estimate | Adjusted/Notes |
| Mortgage Rent | ||
| Second Mortgage / Land or Lot Payment | ||
| Electricity | ||
| Heating | ||
| Water/Sewer | ||
| Telephone Car or Cell Phone / Pager | ||
| Property Tax (if not escrowed) | ||
| Home Maintenance / Security System | ||
| Garbage Service | ||
| Pest Control / Termite Bond | ||
| Food | ||
| Groceries | ||
| Food at Work (daily average X 20 days) | ||
| School Lunches (daily average X 20 days) | ||
| Eating Out (weekends or nights) | ||
| Car | ||
| Gasoline | ||
| Car Repairs, Maintenance | ||
| Car Payment / Bus / Parking / Car Pool | ||
| Car Tags | ||
| Personal | ||
| Personal Items / Toiletries | ||
| Barber / Beauty Shop | ||
| Allowances for Children | ||
| Child Care | ||
| Child Support / Alimony | ||
| Tobacco / Alcohol | ||
| Insurance | ||
| Automobile | ||
| Homeowners (if not escrowed) | ||
| Life (if not payroll deducted) | ||
| Medical | ||
| Doctor Visits (yearly average / 12 months) | ||
| Medication | ||
| Dentist (yearly average / 12 months) | ||
| Clothing | ||
| Clothing (yearly average / 12 months) | ||
| Dry Cleaning / Laundry | ||
| Gifts & Donations | ||
| Birthday (yearly average / 12 months) | ||
| Christmas | ||
| Other Gifts (Anniversaries, Mother's Day, etc...) | ||
| Church Donations / Charities | ||
| Tuition / School Fees | ||
| School Books / Supplies | ||
| Professional Dues | ||
| Entertainment | ||
| Movies / Video Rentals / Plays | ||
| Cable TV / Online Computer Service | ||
| Books / Magazines / CDs | ||
| Other | ||
| Postage / PO Box Rental / Safety Deposit Box | ||
| Pet Supplies / Vet Bills (yearly average / 12 months) | ||
| Fee on checking account | ||
| SAVINGS / EMERGENCY FUNDS | ||
| Other | ||
| Total: |
Net Monthly Income $________________________
CCCS Payment $______________________
Monthly Expenses May Not Exceed $___________________
| Click Here for listings and descriptions of CCCS Services |