Free Online Credit Evaluation by Verus Financial

First Name    Last Name  

Email Address     

(If you do not enter a valid e-mail address we can not respond to your request for a Free Evaluation)

Contact #1   Home Phone Cell Phone Work Phone

Contact #1 Phone Number  

Can we leave a message? Yes No

Contact #2  Home Phone Cell Phone Work Phone

Contact #2 Phone Number 

Can we leave a message?  Yes No

Best time to call   Morning 9:00 am to 12:00 pm EST Afternoon 12:00 pm to 4:00 pm EST Evening 4:00 pm to 7:00 pm

Do you have copies of all three of your credit reports?   yes  no

     1.  Have you ever filed Bankruptcy?   yes  no

   What Chapter was it?   7   or  13   not sure

         When was it filed?    

         When was it discharged? 

     2.  Do you have any Tax Liens?    yes    

         Are they paid or satisfied?   yes   no

         How long ago was it filed?   

         How long ago was it satisfied?

     3.  Do you have any Judgments?   yes  no    

         Are they paid or satisfied?   yes  no

         How long ago was it filed?

         How long ago was it satisfied?

     4.  Do you have any other Public Records information?   yes   no 

         What is it?   Is it satisfied?  yes  no    

         How long ago was it satisfied? 

     5.  Do you have Collections accounts (even medical)?  yes  no   

     How old are they?       Are they paid?  yes   no  

         How long ago were they paid? 

     6.  Do you have Charged Off accounts? yes    

         How long ago were they charged off?     

         Are they paid now?  yes no    

         How long ago did you pay them? 

     7.  Have you ever had an Automobile Repossessed?   yes   no   

         How long ago? 

     8.  Have you ever had any real estate go into Foreclosure?   yes  no 

         How long ago?         

         Do you still have an open mortgage with the same company?  yes  no

     9.  Do you have any Late Payments?   yes  no

         How late were you (30,60, 90)? 

         How long ago were you late?

         Are the accounts open or closed?  open   closed

    Is there anything else you would like to tell us about your credit situation?

    How did you find us? (If by search engine, do you remember which one?)

   Have you already spoken it a counselor in our office? yes no

   If yes, do you remember their name?

Thank you for taking the time to fill out this evaluation sheet.