Tell Us Your Story

Who You Are

Let's start with your basic info so your legal team can find your file.

First Name *

Please enter your first name.

Last Name *

Please enter your last name.

Email Address *

Please enter a valid email address.

Mobile Phone *

Please enter a valid 10-digit phone number.

What Happened

Tell us about the event or situation that made things difficult.

What happened that made it difficult or impossible to keep up with your payments? *

Select all that apply.

Job loss or reduced hours Medical emergency, illness, or hospitalization Disability (short-term or long-term) Divorce or separation Death of a spouse, partner, or household wage earner Military deployment or service-related hardship Natural disaster (hurricane, fire, flood, etc.) Unexpected caregiving responsibilities Other

Please select at least one option.

In your own words, what happened? *

A few sentences is all we need. Focus on when it started and what changed in your life.

0/500

Please describe what happened.

How It Affected Your Finances

This helps your legal team show the financial impact on your life.

How has this affected your ability to pay for basic necessities like housing, food, and medical care? *

0/500

Please describe the financial impact.

Do you or anyone in your household currently receive any of the following? *

Select all that apply.

Social Security (SSI or SSDI) Disability benefits (short-term or long-term) Workers' Compensation SNAP (food assistance) Medicaid or Medicare TANF (cash assistance) Housing assistance or vouchers LIHEAP (utility assistance) None of the above

Please select at least one option.

Is any of the income listed above the primary source of income for your household? *

Yes No

Please select an option.

Looking Ahead

Help your legal team understand what to expect going forward.

Over the next 12 months, do you expect your financial situation to: *

Get better Stay about the same Get worse I'm not sure

Please select an option.

Why do you feel that way? *

A sentence or two is fine.

0/300

Please share your reasoning.

Your Path Forward

This helps your legal team position the strongest case possible.

Have you considered filing for bankruptcy? *

Yes No I'm not sure

Please select an option.

What made you choose this path instead of bankruptcy? *

Select all that apply.

I want to try to resolve my debts without bankruptcy if possible I'm worried about how bankruptcy would affect my credit long-term I can't afford to file for bankruptcy Someone advised me to try this first Other reason

Please select at least one option.

If your debts can't be resolved through this program, would you consider bankruptcy as a last resort? *

Yes No Possibly

Please select an option.

The Human Side

We know this is personal. Your answer helps your legal team show the real impact this situation has had on your life. You don't have to share anything you're not comfortable with.

How has this debt situation affected your mental health, your relationships, or your day-to-day life? *

0/500

Please share how this has affected you.

Your Monthly Budget (optional)

This last part is optional, but it can strengthen your case.

A clear picture of your income and expenses helps your legal team show the court (or a creditor) that you genuinely can't pay. If your budget shows extra money left over each month, creditors are far less likely to offer a settlement or forgive what you owe. So if you fill this out, include every expense you can think of. Leave anything you don't know blank.

Don't want to share this?

Sources of Income

Check any that apply to your household.

Monthly Income

Gross monthly income

Federal tax deduction

State tax deduction

FICA tax deduction

Health insurance deduction

Child support deduction

Alimony deduction

Monthly Expenses

Cable TV / streaming

Auto payment

Auto insurance

Gasoline

Cell phone

Groceries

Medical insurance

Prescriptions

Student loans

Child care

Healthcare (out of pocket)

Life insurance

Clothing

Household items

Laundry

Utilities

Mortgage

Homeowners insurance

Property taxes

Water / sewer

Rent

Back taxes

Pet care

Religious donations

Payment to Card Shield

Entertainment

Propane gas

Cigarettes

Gross monthly income$0.00

Total payroll deductions$0.00

Net monthly income$0.00

Total monthly expenses$0.00

Monthly disposable income$0.00

Tell Us Your Story

Who You Are

What Happened

How It Affected Your Finances

Looking Ahead

Your Path Forward

The Human Side

Your Monthly Budget (optional)

Got it. Your story has been sent to your legal team.