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First Name
Last Name
Phone Number
Zip Code
Email Address
Total Debt
Under $5k
$5k - $10k
$10k - $20k
$20k - $50k
Over $50k
Total Monthly Income
Under $1k
$1k - $5k
$5k - $10k
$10k - $15k
Over $15k
Total Assets
Under $50k
$50k - $500k
$500k - $1m
Over $1 million
Do You Own Real Estate?
Yes
No
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