Home Intake 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?

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.

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