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	Product	Type	Total
	Counseling In Motion	Joint/Couple	$35

Cart Subtotal: $35

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First Name

Last Name

Spouse First Name

Spouse Last Name

Address

City / Town

County

State

Zip

Phone

E-Mail

Attorney

Attorney (if other)

Attorney E-mail (if other)

Employer (if any)

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Operations	Result
Cart Subtotal	$35
Promo Code
Total	$35

Note: We recommend using a DEBIT card for purchasing counseling or bankruptcy classes.

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