Free Debt Settlement Consultation

You Must Have at Least $10,000.00 of Unsecured Debt to Qualify for Acceptance

To begin your path to debt relief and financial recovery, please complete the following application. Items marked with a red star * are required. This form will be sent directly to the Johnson Law Group staff and will be kept strictly confidential.

Personal Information

First Name:	*
Last Name:	*
E-mail Address:	*
Spouse Name:
Current Address:
City, State:
Zip Code:
Home Phone:	*
Cellular/Pager #:
Work Phone:
Fax:
Best # to Call:
Best time to call:	Morning Afternoon Evening

Income And Expenses

Net Monthly Income (After taxes):
Total Monthly Expenses (Rent or mortgage, utilities, food, car payment, etc.):
Total Savings (Include savings accounts, checking accounts, and investments):

Creditor Information

Creditor	Balance	Monthly Payments	Type

Total Amount of Unsecured Debt
(Include credit cards, medical bills, collection accounts, judgment's, etc.):

* Required Fields