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Estimated amount of debt $ Please Select Under $5,000 $5,000 - $6,000 $6,000 - $7,000 $7,000 - $8,000 $8,000 - $9,000 $9,000 - $10,000 $10,000 - $11,000 $11,000 - $12,000 $12,000 - $13,000 $13,000 - $14,000 $14,000 - $15,000 $15,000 - $16,000 $16,000 - $17,000 $17,000 - $18,000 $18,000 - $19,000 $19,000 - $20,000 $20,000 - $25,000 $25,000 - $30,000 $30,000 - $35,000 $35,000 - $40,000 $40,000 - $45,000 $45,000 - $50,000 $50,000 - $55,000 $55,000 - $60,000 $60,000 - $65,000 $65,000 - $70,000 $70,000 - $75,000 $75,000 - $80,000 $80,000 - $85,000 $85,000 - $90,000 $90,000 - $95,000 Over $100,000

My payments are (worst case) Up-to-date 1-3 months past due 3-6 months past due 6-9 months past due 9-12 months past due Over a year past due

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