Thank you for contacting BALANCE.

1 Dear Client, The following is a worksheet for you to use to record your existing financial situation. Please print it out and complete it prior to your meeting. There is no need to send us a copy; during your hour-long counseling session, your counselor will ask you for this information. A recent paycheck stub and your current creditor statements are also helpful to have available. If you are married, please provide the information for both you and your spouse. We ve also included a counseling agreement. Please take a moment to read it over before your you are unable to keep your appointment, please contact us as soon as possible at 888-456-2227 and we ll be happy to reschedule. Otherwise, your counselor will call you at the appointed time. We look forward to speaking with you.

2 Regards, Kathryn DavisPresident & Chief Executive Officer595 Market Street, 16th Floor San Francisco, CA you for contacting Financial AssessmentBALANCE offers financial information and counseling nationwide to help individuals and families make the most of their money. We offer solutions for those experiencing a financial crisis, suggestions and guidance for those facing money challenges, and practical information for those considering financial opportunities. Each year, we help thousands achieve their financial goals. During this call, you can expect to receive thorough, non-judgmental counseling. The session will include a discussion of your current situation and your concerns, including a review of your income, expenses and debt, an explanation of your options, and an action plan.

3 If you are having trouble keeping up with your bills, one of your options might be consolidation of your bill payments. Our Debt Management Plan allows you to make one payment to all your creditors through us. We will also negotiate with your creditors to stop collection action, lower payments and, in some cases, reduce or eliminate interest and Market Street, 16th Floor San Francisco, CA use this worksheet to record your existing financial situation. There is no need to mail this form back to us. During the call, the counselor will ask you what you entered for each category, and will use this information to offer solutions and suggestions to help you master your money. Calculate your monthly income. Please enter your gross pay (before taxes and other deductions) and your net pay (face value of your check).

4 Include variable income received each month, such as commissions, as well as periodic income, such as a large tax refund or bonus. This will have to be divided by 12 to get the monthly INCOMEGROSS INCOMENET INCOMEPARTNER S GROSSPARTNER S NETI ncome Source/EmployerPart Time Employer/Second JobRetirement/PensionChild Support/AlimonySocial SecurityFood StampsUnemployment InsuranceSupport from Family/FriendsRental IncomeOther Income (variable or periodic)Other Income (variable or periodic)Total Monthly IncomeASSETS & LIABILITIESPRESENT VALUEAMOUNT OWEDMONTHLY PAYMENTHome MortgageSecond MortgageOther Mortgage/HELOCV ehicle Payment #1 Vehicle Payment #2 Property/Land401(k)/403(b) LoanOther Payments ( vessel, RV, time-share, additional vehicles, etc.)Total Assets & LiabilitiesOTHER INVESTMENTSPRESENT VALUEMONTHLY CONTRIBUTIONPROPOSED CONTRIBUTION401(k)/403(b) ContributionSavings AccountIRAM oney Market/Stocks/CDCash Value Life InsuranceOther:Total Other InvestmentsDon t forget toinclude yourpayroll deducted 401(k) - 403(b) ExpensesFor all categories that apply to you, enter the monthly amount you spend.

5 Many expenses fluctuate each month and will need to be averaged. Other expenses may be periodic (such as insurance, vehicle registration and taxes). Calculate the annual amount and divide by 12. HOUSINGCURRENTPROPOSEDM ortgage/Rent2nd Mortgage/Equity LineHomeowner s/Renter s InsuranceProperty TaxesCondo Fees/HOA DuesHome MaintenanceLawn/Garden/PoolMonitored AlarmGas/Electric (average)Water/Sewer/GarbageLandline/Cel l PhoneCable/SatelliteInternetFOODCURRENTP ROPOSEDG roceries/Household ItemsFood at Work/SchoolDining OutAlcohol/CigarettesMEDICALCURRENTPROPO SEDD octor/ChiropractorOptometrist/LensesDent ist/OrthodontistPrescriptionsHealth/Dent al/Vision InsuranceLife/Disability InsuranceTRANSPORTATIONCURRENTPROPOSEDV ehicle Payment #1 Vehicle Payment #2 Auto InsuranceDMV RegistrationGasoline/OilMaintenance/Repa irsPublic Transportation/Tolls/ParkingMISCELLANEOU S OBLIGATIONSCURRENTPROPOSEDF ederal Tax RepaymentState Tax RepaymentStudent LoansUnion DuesChild Support/AlimonyPERSONALCURRENTPROPOSEDB eauty/BarberClothing/JewelryCosmetics/Ma nicureLaundry/Dry CleaningENTERTAINMENTCURRENTPROPOSEDM ovies/Concerts/TheaterBooks/Magazines/Ne wspapersCD/DVDS

6 Ports/Hobbies/MembershipsVacations/Trave lMISCELLANEOUSCURRENTPROPOSEDC hildcare/Daycare/BabysittingTuition/Less onsPet CareStorage FeesBanking FeesPostageHoliday/Birthday/GiftsCharity /Religious ContributionsOther:Other:Other:Other:Oth er:Other:SAVINGSCURRENTPROPOSEDE mergency/Misc. Savings3 Current DebtsPlease list all unsecured debts with balances over $100. Do not include mortgage, vehicle or student loans. List these loansin the appropriate categories on the previous expense information page. Please have your current creditor statements available during your counseling session. )(3(5*, 9,= NAME OF CREDITORACCOUNT NUMBERMONTHS LATECURRENTBALANCECURRENTPAYMENTINTEREST RATE1234567891011121314151617181920 Agreement Please read the following statements carefully. At the time of your counseling session, your verbal acceptance of this agreement will be I understand BALANCE will provide a personal money management consultation after which I will receive a written action plan consisting of recommendations for handling my finances, possibly including referrals to other services or agencies as One of the possible outcomes of the consultation may be to repay my creditors through a Debt Management Plan.)

7 I understand that BALANCE and its affiliate companies receive funding from those creditors and that the Debt Management Plan serves the dual role of helping me repay my debts and helping creditors collect the money owed A counselor may answer questions regarding financial issues, but not give legal At some time in the future, information discussed in the counseling session, or obtained from my credit report, may be used for confidential research and/or a neutral third party may contact me to request an evaluation of the agency s services. 5. I hold BALANCE, its employees, agents, and volunteers harmless from any claim, suit, action or demand of my creditors, myself or any other person resulting from advice or counseling.

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