When did you begin the program?
When did you exit the program?
In what state were you residing at the time you entered the program?		Please Select AKALARAZCACOCTDCDEFLGAHIIAIDILINKSKYLAMAMDMEMIMNMOMSMTNCNDNENHNJNMNVNYOHOKORPARISCSDTNTXUTVAVTWAWIWVWY
What is your household annual income?		Please Select $10K-15K$15K-20K$20K-30K$30K-40K$40K-60K$60K and above
What is your age range?		Please Select 21-2930-4040-5050-6060-7070 and above
Are you male or female?		Please Select Male Female
Do you rent or own your home?		Please Select Rent Own
How many members are in your household?		Please Select 1234567 or above
Do you consider your program experience a success?		Please Select Yes No
Do you feel better able to handle your remaining or future debt?		Please Select Yes No
What is the total amount of debt enrolled in the program?		Please Select $10K-15K$15K-20K$20K-30K$30K-40K$40K-60K$60K and above
Were you late on your debt payments prior to starting the program?		Please Select Yes No
Did you interview more than one debt settlement company?		Please Select Yes No
How did you locate the debt settlement company(s) that you interviewed or chose?		Please Select Television commercialRadio commercialInternet adPrint ad (i.e. newspaper, newsletter, billboard, magazine)Personal referralNational association referralYou were contacted by companyReferred by credit counseling agencyReferred by bankruptcy attorneyOther (Please explain)
If other please explain.
What factors influenced your decision in choosing a debt settlement company? (check all that apply)		Location of the companyTotal fees charged by the companySchedule in which fees were chargedPercentage of savings quotedCourteousness of representativeLength of time spent explaining all aspects of programLength of time company has been in businessPerformance record reported by the Better Business BureauPerformance record reported by other agencyMembership with a national organizationCertified financial counselorsLegal assistance provided if necessaryOther (please explain)
If other please explain.
On a scale from 1-5, 5 being excellent, 1 being poor, how would you rate the following aspects of the debt settlement company you worked with?
Courteousness of company representatives
Thorough explanation of program
Ability to reach customer service
Issue resolution
Timely return of calls
Accuracy of percentages saved
Disclosures – did company disclose the following information to you prior to signing an agreement with company?
Total fee amount being collected by company		Please Select Yes No Cannot Remember
Fee schedule		Please Select Yes No Cannot Remember
Projected percentage of settlement savings		Please Select Yes No Cannot Remember
Possibility of being sued by one or more creditor		Please Select Yes No Cannot Remember
Other debt solutions available		Please Select Yes No Cannot Remember
Right to cancel agreement		Please Select Yes No Cannot Remember
Fee accessed when agreement is cancelled		Please Select Yes No Cannot Remember
Refund policy		Please Select Yes No Cannot Remember
Estimated length of time in program		Please Select Yes No Cannot Remember
Company cannot guarantee to stop creditor calls		Please Select Yes No Cannot Remember
Non-payment to creditors may negatively impact your credit		Please Select Yes No Cannot Remember
Debt settlement is not credit counseling, debt consolidation, legal advice, credit repair or a loan		Please Select Yes No Cannot Remember
Forgiveness of debt over $600 may be reported to the IRS as income		Please Select Yes No Cannot Remember
Company will not be making regular payments to your creditors		Please Select Yes No Cannot Remember
All statements are estimates, not guarantees		Please Select Yes No Cannot Remember
Did company conduct a financial review prior to contract?		Please Select Yes No
Did company contract include the following?
List of all debts to be included in the settlement program		Please Select Yes No
List terms and conditions of services being rendered, including fees, estimated amount needed to fund settlement and estimated installments necessary to achieve that goal		Please Select Yes No
State name, physical address and telephone number of company		Please Select Yes No
Did company provide you with copies of all signed paperwork?		Please Select Yes No
Did company provide you with proof of settlements?		Please Select Yes No
Where did you remit funds for settlement?		Please Select Savings account set up and maintained by youTrust account maintained by third partyDirectly to company
Did a creditor file suit against you while in the debt settlement program?		Please Select Yes No
Did you experience a non-typical hardship prior to seeking debt settlement assistance?		Please Select Yes No
What is the primary reason that debt assistance became necessary for you?		Please Select Increased interest ratesHoliday expensesNon-typical hardshipEase of obtaining creditDeceptive credit card promotionsHigh level of debt incurred while attending collegeDivorceOther (Please explain)
Would you refer a friend or colleague to this company?		Please Select Yes No
Did the value of service equal or exceed the amount of fees paid?		Please Select Yes No
Did debt settlement ultimately improve your financial situation?		Please Select Yes No
During your debt settlement program did you gain knowledge that will help you avoid financial trouble in the future?		Please Select Yes No
If yes, select all that apply	Financial education program provided by companySavings regimenCompany offered informative advice and tips through newsletter or publicationCompany offered informative advice and tips on websiteCompany recommended a financial education program offered by third partyYou are motivated to remain out of financial distress