Your First Name *

Your Last Name *

Your Street Address *

City *

State *

Zip Code *

Phone Number *

What is your date of birth? *

What is the last 4 of your Social Security Number? *

Email Address *

Spouse First Name

Spouse Last Name

Spouse Street Address

Address Line 2

Spouse City

Spouse State

Spouse Zip Code

Spouse Phone Number

Spouse Email Address

What is the last 4 of Spouse your Social Security Number?

What is your Spouse date of birth?

which enrollment fee are you paying today? *

Single ($179.99)

Couple ($249.99)

What Monthly Plan Are You Signing Up For? *

Do you understand that credit monitoring is REQUIRED, and it will debit your account every 30 days and it is $24.99 a month? *

Are you currently behind on any bills? *

Yes

No

Do you have a stable income? (Guaranteed money that comes weekly, bi-weekly, and/or monthly?) *

Yes

No

Is there anything going on financially at this current moment that will prevent you form paying any bills on times and this includes your monthly payments for credit repair as well? *

Yes

During the credit repair process if any new inquires are added that we are not aware of our system will automatically cancel the membership. Is there anything coming up on your end that you know for a fact your credit will be getting pulled for within the next 6-9 months? *

Yes

No

Very Briefly, tell us why did you reach out for credit repair? *

What questions did you want to discuss during your first call with your credit specialist? *

RECURRING PAYMENT AUTHORIZATION - CREDIT / DEBIT CARD

By signing, I authorize Credit Miracles LLC to automatically charge the card I have designated to pay for the services I purchased from Credit Miracles LLC in accordance with the payment schedule and terms of my
new client contract.

I agree and authorize Credit Miracles LLC to adjust the payments to reflect any late fees that occur during the term of the service.

If I have designated a debit card, I acknowledge my responsibility to ensure there are sufficient funds in my bank account at the time of each scheduled debit. If there are insufficient funds in my account, I understand Credit Miracles LLC may charge me an NSF fee and that Credit Miracles LLC may at its discretion attempt to process the charge again within 30 days with avoid cancellation.

I also understand that my membership may cancel or expire due to nonpayment if an automatic
payment is rejected.
I understand that this authorization will remain in full force and effect for the remainder of the membership or
until Credit Miracles has received a written notice from me of its termination.

I agree to notify Credit Miracles LLC in writing of any changes to my credit/debit card information or termination of this authorization at least 3 business days prior to the next billing date.

If my scheduled payment falls on a weekend or holiday, I understand that the
payment may be executed on the day I select in this agreement.

I acknowledge that the origination of transactions to my account must comply
with the provisions of U.S. law.

I certify that I am an authorized user of this credit card/bank account and will not dispute the
scheduled transactions with my bank or credit card company; provided the transactions correspond to the terms indicated in this authorization form. Credit Miracles LLC reserves the right to terminate this Authorization and require me to pay my installments by an alternative method.

Name on Card *

Credit Card Type *

Credit Card Number *

Expiration Date (mm/yy) *

Before signing the agreement, please make sure you have read everything in full. Sign once you have read and agree to everything above. * 🛈

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