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Online Registration Form

You may complete this application and submit it on-line, or print out the form, complete it, then fax it to us at (319) 234-7533.
Be sure to keep a copy for yourself when you call in to speak to a counselor.

Applicant's Information

  

Spouse's Information
Last Name:

First Name:

Middle Name:

Email:
 Date of Birth:
  Last Name:

First Name:

Middle Name:
 Date of Birth:

Applicant's Information

  

Spouse's Information
Last Name:

First Name:

Middle Name:

Email:
 Date of Birth:
  Last Name:

First Name:

Middle Name:
 Date of Birth:
Present Address:
  
City:

ZIP:
 State:

Home Phone:
   # of Children:

Ages
Employer:
 Position:
   Employer:
 Position:
Employer's Address:
 Work Phone:
   Employer's Address:
 Work Phone:
Client's Payday(s)
 Gross Pay Check
 Take Home/ Payday

Monthly Take Home
Spouse's Payday(s)
 Gross Pay Check
 Take Home/Payday

Monthly Take Home
       

OTHER INCOME

Child Support
 Part Time
Social Security
 Etc.

Other Income
   

Total Take Home Income

Basic Monthly Budget

Bills Without Credit Debt or Loan Payments
(To Be Completed by Prospective Client)
Monthly Expenses Counselor Suggested
Expenses
Rent Payment
Mortgage Payment
Taxes/ Insurance on House
Utilities (light, gas, water, cable)
Phone

HOUSING TOTAL
     
Groceries (Food Purchased)
Food away from home

GROCERIES / FOOD TOTAL
     
Insurance (Auto/Life/Med)
Auto (Gas)

AUTO TOTAL
     
Cigarettes
Soap/shampoo/dry products/diapers
Clothing
Lottery/Gambling
Prescriptions (not covered by Insurance)
Miscellaneous

PERSONAL TOTAL
     
Alimony/Child Support Paid (not deducted from paycheck)
Car Payment
Student Loan Payment
Day Care
IRS Payments (not deducted from paycheck)
State Tax Payments (not deducted from paycheck)

OTHER TOTAL
     

TOTAL EXPENSES
     
Do You Use A Checking Account? Yes   No
Have You Had Overdrafts? Yes   No
Do You Use Cash Advances to Pay Bills? Yes   No

Client Worksheet


Please list all your outstanding debt including car payments, retail and charge card accounts, credit union and bank loans, delinquent taxes, family and personal loans, student loans, etc. Please list those accounts that are deducted from your payroll or bank account. It is important to list all debts, whether your account is current or past due. Fax your most current statements.


Name of Creditor
Complete Mailing Address		 Telephone Number Balance Mthly Payment # Mths Delinq
1.
2.
3.
4.
5.
6.
7.
8.
9.
10.
11.

Click Here to Print This Page

Then click "Submit" to send the information to us.

Impact Marketing Technologies, Inc.