Debtco Client Submission Form

We Never Give or Sell Your Information to Third Parties

The following are guidelines for submitting deals to DEBTCO. DEBTCO may choose to arbitrate deals that do not match these criteria on a case by case basis. If you would like a Printable Application to Fax or Mail, Please Click Here to download. *All downloadable forms from this site require Adobe Acrobat Reader.

To submit your client for Debt Arbitration, please complete the following application. Items marked with a red star * are required. This form will be sent directly to DEBTCO staff and will be kept strictly confidential.

You must have at least $5,000.00 of unsecured debt and a credit score of 600 or Less to qualify for acceptance into our program.

Broker Information

First Name:	*	Last Name:	*
Company Name:		Work Phone:
Current Address:		Fax:
City, State:		Zip Code:
E-mail Address:	*

Title Company:	*
Title Company Address :
Best # to Call:		Morning Afternoon Evening
Does the Client Know We Will be Contacting Them?		Yes No

Client Information

First Name:	*	Last Name:	*
Spouse Name:		Home Phone:	*
Current Address:		Cellular/Pager #:
City, State:		Zip Code:
Work Phone:		Fax:
E-mail Address:	*
Best # to Call:		Morning Afternoon Evening
Property Value:		Estimated Close Date:
New Loan Balance:		Mortgage Balance:

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.):

Describe Summary of Client Situation Below:

Please Fax (877.327.4737) the Following Information:

Updated Credit Report
Copy of 1003 Form - If the Form has not been completed yet - Please click here to download form 1003 (Universal Residential Loan Application) and fax the completed form Along with your application.

* Required Fields