Home Intake Form

Financial Counseling Intake Form

Please provide the following information by answering the brief questions shown below.
Information provided is protected as confidential information. If participating as a couple, each individual needs to complete this form.

Name

Date

Member Number

Email Address

Cell Phone

Home Phone

Work Phone

Preferred Method of Contact

Cell Phone
Home Phone
Work Phone
Email
 

Referral Source: How did you hear about us?

Alexandria Branch
DC Branches HHS & C Street)
Philadelphia Branch
Silver Hill Branch
Call Center/Member Services
Collections Dept.
Lending Dept.
Mortgage Dept.
Website
Word of Mouth
Other
 

Other (please explain)

What are your Financial Goals? (Please check all that applies)

Budgeting
Credit Review/Repair
Debt Management/Restructuring
Seeking Loan from Democracy FCU
Pre-Purchase (Home Purchase/Preparation)
Other
 

Other (please explain)

Signature:

Authorization to Release: By checking this box, I authorize the Financial Counseling Service to release any information pertaining to my debts, obligations, liabilities, or credit in attempting to budget, or in budgeting, similarly any information pertaining to my assets, earnings, finances, or prospects to parties that would be directly divulged in assisting in Financial Counseling Services as deemed necessary for the betterment of my financial conditions. On occasion, it will be necessary to exchange personal information with other individuals or companies to set up your Debt Management Plan or any Financial Counseling Services.

Security Please enter the code shown in the image