Debt Counseling Corp.
3033 Expressway Drive North
Hauppauge, NY 11749
Phone: 1.888.354.6332

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First Name *
  Last Name *
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Primary Phone
  Secondary Phone
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  Total Amount of Unsecured Debt
Creditor Name Interest Balance Current Payment Amount No. of Months Past Due Type of Debt If Credit Card, please provide first 6 digits of Credit Card number

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