A non profit community service agency helping people with finances
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A. Tell us about yourself
Tell us what financial concerns you currently have.
* indicates required fields
Date of Birth:
If married, name of spouse:
Date of Birth:
Number of children living in your home:
Have you ever received credit counseling before?
Approximately, how much federal tax refund, if any, did you receive last year?
B. How can we contact you?
Your Work Phone:
Spouse work phone:
(Any person other than you or a spouse, whose name appears on any creditor statement)
D. Monthly Household Income
(All sources of income used for living expenses)
Pay Periods Per Month
Take Home Per Period
Total Monthly Net Take Home Income:
Estimated Annual Gross Income:
E. Living Expenses
Estimate your monthly living expenses below. Round all figures to the nearest whole dollar. Don't include any amounts that are payroll deducted.
Natural Gas, Propane
Cell Phone, Pager
Cable TV, Satellite, Internet
Groceries, Toiletries, Cleaning Supplies
Lunch, Vending at Work
Medical, Prescription Drugs
Car Maintenance & Repair
Health, Life Insurance
Homeowner's, Renter's Insurance*
Real Estate Taxes*
Personal Property Taxes
Tithe, Offerings, Charity
Dry Cleaning, Laundromat
Tuition, Books, Supplies
Barber, Beauty Shop
Other: Pets, Club Dues, Misc.
* Do not list if included in house payment
List all debts not included under Living Expenses in the previous section. Round all figures to the nearest dollar.
Name of Creditor
G. Counseling Services Agreement
Agreement to gain a better understanding of the counseling process.
1. I understand that Credit Counseling of Arkansas (CCOA) will provide me with a confidential, comprehensive, personal counseling session on money management.
2. I understand there is no charge for counseling. My session will be conducted by a certified credit counselor or qualified professional counselor. All action plans will be reviewed by a certified credit counselor.
3. I understand that CCOA is primarily funded by creditors who make "fair share contributions." These contributions are usually calculated as a percentage of the payments I make through the DMP— up to 15% of each payment received. However, my accounts will always be credited with 100% of the payment made. CCOA will try to work with all of my creditors, even those who do not make this contribution. The DMP serves the dual role of helping me repay my debts and helping my creditors receive the money I owe them.
4. I hold CCOA, its employees, agents and volunteers harmless from any claim, suit, action or demand of my creditors, myself or any other person resulting from advice or counseling given.
5. I will receive a written Plan of Action with recommendations to aid in resolving my financial obligations. These recommendations may include one or more of the following:Handle On My Own — I may continue to handle my finances on my own.
Debt Management Plan - I may choose to enroll in the Debt Management Plan (DMP), in which case CCOA serves as a neutral third party between me and my unsecured creditors. I understand that CCOA charges a monthly maintenance fee for the DMP service. The fee is tiered, and tied to the amount of the monthly disbursement to my creditors (<$200 disbursed monthly = $15/month fee, $200-$274 disbursed = $20 fee, $275-$699 = $25 fee, >$699 =$30 fee/month). I may discuss a fee waiver with my counselor if I feel the fee would be an unaffordable burden. I also understand that my participation in the Debt Management Plan may affect my credit report either favorably or unfavorably, since my creditors have the option of reporting that they are accepting payments through CCOA.
Legal Help — I may be advised to contact a bankruptcy lawyer for further assistance. My counselor may answer general questions about bankruptcy, but cannot give legal advice. Other Agencies — I may be referred to the services of another agency to assist with my particular situation as identified during the counseling session.
6. I understand that in order to assure the quality and improvement of CCOA’s services, its records may be reviewed by an independent accreditation team. As part of this quality control process, members of an outside review team may have access to the records CCOA keeps on my case.
7. I understand that in the event I am dissatisfied, I can utilize the Complaint Resolution Process below.
Step 1: I will try to resolve the issue with the staff member involved.
Step 2: If step one is not possible or successful, I may write or call the Director of Counseling, who may ask to meet with me or seek more information from the staff member. The Director of Counseling will respond within 15 days.
Step 3: If my issue is still unresolved, I may appeal in writing directly to the Executive Director who will provide a concluding decision within 15 days.
H. Statement of Privacy and Confidentiality
In order to make sure you are an informed consumer, the agreement below describes the nature of our budgeting/debt management services. By submitting this data sheet online, you acknowledge that you understand and agree to the following statements. This does not commit you to a course of action. It only serves to acknowledge that you were informed of the nature of the service, and of our Statement of Privacy & Confidentiality in Section H. below.
Credit Counseling of Arkansas is committed to maintaining your privacy. We assure you that all information shared with us will be managed within legal and ethical considerations. It is only with your specific authorization that we release your personal financial information to your creditors and others directly involved in your Debt Management Plan. We may also use case file information for the purpose of researching, evaluating, and improving our services, in which case your anonymity will be maintained through the use of your client number, or by compiling statistical data. In all other situations, your financial information may be released to appropriate individuals or agencies ONLY UPON YOUR WRITTEN REQUEST or when we have been served by a valid subpoena.
The following practices govern our efforts to maintain your privacy:The following practices govern our efforts to maintain your privacy:
1. We do not disclose any nonpublic personal information about our clients or former clients to anyone, except as required by law.
2. We may compile data and information that you give to us, but this information may not be disclosed in a manner that would personally identify you in any way.
3. We may disclose some or all of the information that we collect, as described below, to creditors, related financial institutions, or third parties that you have authorized who need this information in order for us to assist you. This information is collected from the following sources:From you, on our applications or other forms that you provide, such as your name, address, social security number, assets, and income. From your transactions with us, your creditors, and others, such as your account balances, payment history, parties to transactions and credit card usage.
4. Access to nonpublic personal information about you is restricted to those employees who need the information to provide services to you. We maintain physical, electronic and procedural safeguards that comply with federal regulations to guard your nonpublic personal information.
5. Client data sheets are disposed of (shredded) if there is no follow-up contact after approximately six months. Electronic records of appointment dates and counseling notes are maintained electronically, and are not purged.
RELEASE: I authorize Credit Counseling of Arkansas, Inc. to release all nonpublic information it obtains about me to my creditors and any third party necessary to resolve the matters discussed during my counseling session. I also release and authorize all of my creditors to provide nonpublic information about me to Credit Counseling of Arkansas. Credit Counseling of Arkansas pledges that you have the right to: > Prompt counseling services for managing money based on your financial situation. > Courteous assistance with dignity and respect. > Active involvement in an assessment of your financial situation including a Plan of Action. > Express dissatisfaction through a Complaint Resolution Process. > Discontinue your relationship with CCOA at any time by providing written notice. > Ask questions and to have your concerns addressed.