Basic Data Sheet

Personal Information

Contact Information



Personal Information

* fields are mandatory

Contact Information

* fields are mandatory

Monthly Take-Home Income

** All sources of income used for living expenses.

Place of Employment Pay periods/Month Take-Home/Period Monthly Sub-total
Your Income: X =
Spouse/Partner Income: X =
Other: X =
Other: X =
Total Monthly Net Income $

Monthly Living Expenses

** Estimate your monthly living expenses below. Round off figures to the closest dollar amount. Don't include any amounts that are payroll deducted.

Second Mortgage
Vehicle 1
Vehicle 2
Natural Gas, Propane, Heating
Cell Phone, Pager
Cable TV, Satellite, Internet
Groceries, Toiletries, Cleaning
Lunch & Vending at Work
School Lunches
Dinners Out
Child Care
Child Support
Medical, Prescription Drugs
Car Maintenance & Repair
Car Insurance
Health, Life Insurance
Homeowner's, Renter's Insurance
Real Estate Taxes
Personal Property Taxes
Dry Cleaning, Laundromat
Tobacco, Alcohol
Entertainment, Vacations
Tuition, Books, Supplies, Lessons
Barber, Beauty
Newspaper, Magazine Subscriptions
Tithes, Offerings, Charity
Other:Pet,Club Dues,Misc.

E. Creditors

List all debts/creditors not included under "MonthlyLiving Expenses" in the previous section. Round off all figures to the nearest dollar.

Name of Creditor  Balance   Current Payment Int. Rate

Nondiscrimination Policy Credit Counseling of Arkansas strives to serve all members of the community and does not discriminate in the selection of clients in our programs or services with respect to age, race, religion, color, gender, or disability.

Counseling Services Agreement

  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 (<$199 disbursed monthly = $15/month fee, $200-$274 disbursed = $20 fee, $275-$374 = $25 fee, $375-$474 = $30 fee. $475-$774 = $35, $775-$1099 = $40 fee, >$1099 = $45 fee/month). I further understand that there is a $40 one-time Start-up fee to begin the program. 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.

Statement of Privacy and Confidentiality

I understand that I am responsible for disclosing accurate information, to the best of my knowledge, about all of my creditors and sources of income to CCOA. In order for CCOA to act on my behalf, I authorize CCOA, and its employees, agents/volunteers to disclose any information concerning my financial condition and status according to provisions outlined in the CCOA Privacy Policy. This information would include, but not be limited to, income, debts, credits, earnings, assets and residential and work addresses to any creditor listed by me unless otherwise required by law. I further authorize CCOA to obtain whatever financial information concerning me from my creditors, as CCOA deems necessary. My signature on this form also authorizes my creditors to release my account information to representatives of CCOA.

I have read and I understand the disclosures made above. Signature: