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First Name
Last Name
State
Phone
email
Monthly Income
- Total for Household -
Less than $1000
$1500
$2000
$2500
$3000
$3500
$4000
$4000 - $5000
$5000 - $6000
$6000 - $7000
$7000 - $8000
$8000 - $9000
$9000 - $10000
over $10000
Credit Rating
Select One----------->
Excellent (700+)
Good (620-700)
Fair (580-620)
Poor (580-)