Please complete this form to help us understand your financial situation and tailor our educational program to your needs.
First Name
Last Name
Employee ID
Department
Contact Phone
Email Address
Do you currently have any outstanding debt?
If yes, please provide a brief description of your debts (e.g., auto loan, student loan, etc.):
What is your approximate total debt amount?
$0.00 - $5,000.00
$5,001.00 - $10,000.00
$10,001.00 - $20,000.00
$20,001.00 - $50,000.00
Over $50,000.00
Are you experiencing any of the following financial difficulties? (Check all that apply):
Difficulty paying bills on time
Overreliance on credit cards
Frequent overdrafts
Unsure about budgeting or financial planning
Other:
What are your primary goals for participating in this debt management education program? (e.g., reduce debt, improve budgeting skills, understand credit scores)
Are there any specific financial topics you would like to learn more about?
I understand that the information provided in this form will be treated confidentially and used solely for the purpose of providing educational support.
Employee Signature
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