:::: - Capital Debt Solutions - Pre - Qualifying Form


	Capital Debt Solutions™ Avoid Bankruptcy by settling your debt with CDS..
	Capital Debt Solutions™ Eliminate your debt much sooner than expected.
	Capital Debt Solutions™ Eliminate credit card debt or unsecured debts.
	Capital Debt Solutions™ Debts we work with include: credit cards, unsecured loans, cell phone bills, medical bills.

The following information will be sent to one of our trained specialists in order to determine your acceptance into the program. The specialist will then contact you and assist in working with you to obtain the best fit for your financial needs.

Client
*First name :
Middle Initial :
*Last Name :
*Are you the contracted accounts under another name? (ie maiden name) :	YesNo
*Current Address :
*City :
*State :
*Zip code :
*Home Phone :
Cell Phone :
*Birth date :	(mm/dd/yyyy)
*Employer Name :
*Position :
*Work Phone :
*May we contact you are work :	YesNo
*Contact email address :
*Gross Monthly Income :
*Briefly describe your financial hardship (i.e. Loss of job, medical bills, divorce, living beyond your means, etc) : (Max. 2500 words)

*Required Fields

We will not share your information with any third parties. This information is used solely for the purpose of providing a free consultation.

Capital Debt Solutions does not provide legal, tax, or investment advice.
If you need legal or tax advice, you must consult with a licensed attorney or professional tax advisor.

Full Name

Daytime Phone Number

Email Address

State

Debt Amount