Budget Counseling Worksheet

  • Please provide the following confidential information. Upon receipt of your form, a counselor will contact you to set up an appointment.

    Your Name
    Street address
    Address (cont.)
    City: State: Zip/Postal Code:
    Work Phone: Home Phone:
    E-Mail Address:
    Date of Birth:
    Your Social Security #:

  • Please identify and describe your spouse:

    Name:
    Date of Birth:
    Spouse Social Security #

  • Please list any minor children or others legally dependent upon you and their ages: (example: Bobby Doe, 9 years; Susie Doe, 3 years; Mary Doe, 1 year;)

  • Did someone tell you about our web site? If so, please tell us who. If you heard about it is some other way... tell us that, too!

    Consumer Credit Counseling Service
    1930 N. Eighth Street
    Sheboygan, WI 53081
    Last revised: March 22, 1999