Credit Repair Intake Form

First Name

Middle Name

Last Name

Date of Birth

Social Security Number

Phone Number

Address

Address Line 1

Address Line 2

City

State

Zip Code

Country

Previous Addresses (Last 5 years)

Employer Name (Optional)

Monthly Income Range

Do you currently have access to your credit reports?

Which credit monitoring service do you use? (If none put N/A)

What is your current credit score?

When was the last time you checked your credit report?

What is your primary goal for repairing your credit?

What credit score are you hoping to achieve?

Which negative items appear on your credit?

Do you have active credit cards?

Are any of your accounts past due?

Have you recently applied for new credit?

Have you ever worked with a credit repair company before?

Were any items successfully removed?

Do you currently have a budget? If so what is it?

Are you willing to follow credit-building strategies provided during the program?

Are you willing to keep your credit card usage below 30%

Credit repair requires participation. Are you committed to following instructions and responding to updates?

Are you able to avoid applying for unnecessary credit during the repair process?

Do you authorize Dailey Financial Solutions to review and analyze your credit reports for the purpose of credit repair services?

Electronic Signature

Date