Credit Repair Intake — Jones & Co Signature Services

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Section 01

Personal Information

First Name *

Last Name *

Date of Birth *

Social Security Number * Encrypted and stored securely

Phone Number *

Email Address *

Current Home Address *

City

State / ZIP

Have you lived at this address for 2+ years?

Yes No — I'll include previous address below

Previous Address (if less than 2 years at current)

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Section 02

Current Credit Snapshot

Estimated Credit Score Range *

580 estimated

300 — Poor580 — Fair670 — Good850 — Excellent

Which bureaus have you pulled your report from?

Equifax

equifax.com

Experian

experian.com

TransUnion

transunion.com

Do you have access to your credit reports right now?

Yes, all three Yes, some of them Not yet

Where did you get your credit score from?

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Section 03

Negative Items & Account History

Be as thorough as possible. The more detail you provide, the more targeted your dispute strategy will be. All information is kept strictly confidential.

Approximate # of Collections

Oldest Negative Item (approx. year)

Have you filed for bankruptcy?

No Yes — Chapter 7 Yes — Chapter 13 Filed but Dismissed

List specific creditors / collection agencies you'd like disputed (include account names if known)

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Section 04

Positive Credit Profile

Do you currently have any open accounts in good standing?

Estimated Total Credit Card Utilization

Oldest Open Account (approx. year)

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Section 05

Goals & Timeline

What is your primary reason for repairing your credit? *

Buy a Home Buy / Finance a Car Qualify for Rental Business Funding Lower Interest Rates Employment Background Overall Financial Health

Target credit score goal

When do you need results by?

Have you worked with a credit repair company before?

No, this is my first time Yes — had a good experience Yes — wasn't satisfied

Anything else you'd like us to know about your credit situation or goals?

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Section 06

Financial Overview

Employment Status

Monthly Gross Income (approx.)

Are you currently able to pay bills on time?

Yes, consistently Mostly — occasional struggles No — working on stabilizing

Do you have any active lawsuits, wage garnishments, or IRS liens?

No Yes — I'll describe in notes

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Section 07

Referral & Communication

How did you hear about Jones & Co?

Referred by (name, if applicable)

Preferred contact method *

Phone Call Text Message Email

Best time to reach you

Morning (8am–12pm) Afternoon (12–5pm) Evening (5–8pm) Anytime

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Section 08

Before We Get Started

This intake form is not a service agreement. After your consultation, you will receive a complete Welcome Packet — including your CROA Consumer Rights disclosure, Service Agreement, and Bureau Authorization forms — before any services begin or fees are collected.

Acknowledgment *

I understand I will receive a separate disclosure and service agreement before any services begin

Your Path to
Financial Freedom Starts Here

Intake Received!

Your Path toFinancial Freedom Starts Here

Intake Received!

Your Path to
Financial Freedom Starts Here