Mitigation America, LLC. | Professional Debt Settlement and Mortgage Modification.

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Please fill out each section that applies.

Net Income (Take Home Pay):

Your Net Pay:

Your Spouse's Net Pay:

Other Income:

Monthly Housing Expenses:

Mortgage Lender
(if applicable):

Monthly Mortgage(s) payments including Taxes and Insurance:

Current Interest Rate:

Number of months behind on mortgage:

Current Principal Balance:

Rent (if applicable):

Property Maintenance:

Miscellaneous:

Monthly Auto Expenses (if applicable):

Auto Payment 1:

Auto Payment 2:

Auto Payment 3:

RV Payment:

Estimated Monthly Fuel Cost:

Auto Insurance:

Maintenance:

Creditors (if applicable):


Creditor 1
Creditor Name:	Type:	Account Holder:
Current Balance:	Minimum Payment:	Current Balance:

Creditor 2
Creditor Name:	Type:	Account Holder:
Current Balance:	Minimum Payment:	Current Balance:

Creditor 3
Creditor Name:	Type:	Account Holder:
Current Balance:	Minimum Payment:	Current Balance:

Creditor 4
Creditor Name:	Type:	Account Holder:
Current Balance:	Minimum Payment:	Current Balance:

Monthly Utilities:

Telephone/Cell bill:

Water/Trash/Sewer:

Gas & Electric:

Cable & Internet

Miscellaneous Monthly Expenses:

Clothing:

Dry Cleaning:

Health Club Dues

Cosmetic Expenses (hair, nails, etc.)

Sports/Hobbies:

Dining Out:

Magazine Subscriptions:

Charitable Donations:

Pet Expenses:

Personal Loans:

Minimum Credit Card Payments (Total):

Child Support:

Medical:

Child Care:

Personal Information:

First name:

Last name:

Home Street Address:

City:

State:

Zip:

Home Phone:

Cell Phone:

E-mail:

Mitigation America, LLC
Toll Free: 866-836-1122
Telephone: (443) 708-0259
info@mitigationamerica.com