Financial Dominance

“Today is your opportunity to build the tomorrow you want”

Certified Financial Relief Partner

Official Qualification Questionnaire

Debt Consolidation

Program Eligibility Assessment

Please review and complete all sections below accurately to determine your eligibility for interest reduction and lower monthly payments.

Total Balance$25,600

Current Monthly$825/mo

Est. SavingsUp to $396/mo

Personal & Contact Information

Complete details required for full qualification evaluation and confidential review.

First Name *

Middle Initial

Last Name *

Date of Birth *Must be at least 18 years old

SSN (Last 4 Digits) *Used solely to verify identity

Marital Status

Primary Phone *

Phone Type

Email Address *

Street Address *

Apt / Suite / Bldg

City *

State *

ZIP Code *

Employment & Household Income

Stable earnings are evaluated to determine your capacity for low-interest consolidation.

Employment Status *

Employer / Business Name

Job Title *

Years There

Pay Frequency

Monthly Gross Income (Pre-Tax) *

Base earnings before taxes & deductions

Additional Household Income

Child support, spouse income, SS, pensions

Debt & Creditor Information

List all credit cards, personal loans, medical bills, auto loans, or store cards.

Total Balance ($)	Min. Payment ($)	Interest (%)
$	$	%
$	$	%
$	$	%

Include credit cards, personal loans, medical bills & payday debts

Total Combined Debt Balance *Calculated Total

Total Current Monthly Payments *Calculated Outlay

Real Estate, Assets & Obligations

Equity and asset evaluation for loan qualification.

Housing & Real Estate Status *

Own HomeRentLiving with FamilyOther

Homeowner Asset Details:

Estimated Market Value

1st Mortgage Balance

Monthly Mortgage Payment

Is there a second mortgage, HELOC, or tax lien on the property?

YesNo

Liquid Assets & Vehicles

Vehicles (Est. Total Value):

Savings & Checking Accounts:

401(k) / IRA / Retirement:

Other Investments / Stocks:

Monthly Household Living Expenses (Estimates)

Rent / Lease:

Utilities & Phone:

Groceries & Food:

Transportation / Fuel:

Insurances (Auto, Health):

Childcare / Support:

Healthcare Out-of-Pocket:

Other Living Costs:

Debt Consolidation Goals & Follow-up

Tailor your settlement or loan structure to your desired monthly target.

What are your primary goals for this debt consolidation program?

Target Monthly Payment ($)

Preferred Contact

Best Time to Contact

Are you open to working with a financial advisor to create a custom debt relief plan? *

YesNo

Additional Financial Details or Special Circumstances:

Authorization & Digital Certification

Legal consent, soft credit inquiry authorization, and official e-signature.

Information Certification: I certify under penalty of perjury that all details and financial numbers provided in this questionnaire are true, accurate, and complete to the best of my knowledge.

Soft Credit Evaluation Consent: I authorize Financial Dominance and its certified financial partners to perform a soft credit inquiry to pull account balances and verify credit history. I understand this soft check will not lower or affect my credit score.

Applicant Digital Signature *

Sign above using mouse, touch or trackpad

Sign here

E-Signature Protected & Time-stamped

Date Signed *Time-stamped upon final submission

By submitting this qualification questionnaire, you certify that the details provided are accurate for an evaluation of your debt consolidation options. Submission does not affect your credit score or obligate you to enroll in any program.