Housing Data Sheet | Credit Counseling of Arkansas

Personal Information

Contact information

Home Facing Foreclosure

Monthly Living Expenses

Counseling Services Agreement

Personal Information

Name: *

Social Security #:

Gender:

Birth Date: *

Race:

Highest Education:

Ethnicity:

Household Type:

Job Duration (in Months):

Employer:

Are head of household or spouse considered disabled:

Yes No

Spouse/Partner Name:

Spouse/Partner Social Security #:

Spouse/Partner Gender:

Spouse/Partner Birth Date:

Is this person also on mortgage note:

Yes No

Spouse/Partner's Employer:

Number of Children in your house:

Ages:

* fields are mandatory

Contact information

Address1: *

Address2:

City: *

State: *

Zip Code: *

Email:*

Home Phone:

Cell Phone:*

Work Phone:

Alt. Phone:

* fields are mandatory

Information on Home Facing Foreclosure/Mortgage Concerns

Address1:
(if different with Contact Mailing Address)

Address2:

City :

State :

Zip Code:

Anyone else on mortgage note or deed?

Yes No

Are you currently living in the home:

Yes No

How long have you lived here?

What is your housing goal at this point?

Attempt to resolve the delinquency and stay in the home

Leave the home while minimizing the financial consequences

Undecided

Other (If Other, please explain briefly ):

Maximum 250 Characters

Current Mortgage (answer us much as you can)

Mortgage Company:

Loan Number:

Contact Name:

Phone# :

Fax :

Current Interest Rate:

Fixed Adjustable Interest-Only Payment

Regular Monthly Payment

Taxes & Insurance Included (in escrow)?

# of Months Delinquent

Current Delinquency Amt:

Loan is:

FHA

Rural Housing

Conventional

Other (If Other, please explain briefly):

Maximum 250 Characters

Has Mortgage Company Started or Threatened to Start Foreclosure?

Yes No

If Foreclosure Has Begun, Has a Sale Date Been Set?

Yes No

Date:

Do You Have a Second or Subordinate Mortgage?

Yes No

Amt:$

Have you modified your loan previously?

Yes No

Date:

Explain Underlying Cause of your Current Mortgage Problem

Please explain the underlying causes of your current mortgage problems:

Maximum 1000 Characters

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.

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.

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.

MONTHLY LIVING EXPENSES	Currently
Rent	/month
Mortgage	/month
Second Mortgage	/month
Vehicle 1	/month
Vehicle 2	/month
Natural Gas, Propane, Heating	/month
Water	/month
Electricity	/month
Telephone	/month
Cell Phone, Pager	/month
Cable TV, Satellite, Internet	/month
Groceries, Toiletries, Cleaning	/month
Lunch & Vending at Work	/month
School Lunches	/month
Dinners Out	/month
Child Care	/month
Child Support	/month

MONTHLY LIVING EXPENSES	Currently
Medical, Prescription Drugs	/month
Gasoline	/month
Car Maintenance & Repair	/month
Car Insurance	/month
Health, Life Insurance	/month
Homeowner's, Renter's Insurance	/month
Real Estate Taxes	/month
Personal Property Taxes	/month
Tithes, Offerings, Charity	/month
Dry Cleaning, Laundromat	/month
Tobacco, Alcohol	/month
Entertainment, Vacations	/month
Clothing	/month
Tuition, Books, Supplies, Lessons	/month
Barber, Beauty	/month
Streaming Services	/month
Other:Pet,Club Dues,Misc.	/month

Creditors

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

Balance	Current Payment
$	$	You can add more rows by clicking the "Add Row" button below.
$	$
$	$
$	$
$	$

Monthly Household Income(Net-after Taxes,etc.)


Your Income:	X	=
Spouse/Partner Income:	X	=
	X	=
	X	=
	X	=
Total Monthly Net Income		$

Estimated Gross Annual Income:

Last tax refund:

** Annual Gross income is the total earnings before taxes or other deductions.

Counseling Services Agreement

We understand that you are contacting us to help deal with a mortgage problem. As a HUD- approved housing counseling agency, we are here to provide free, confidential housing counseling to help you resolve your housing concerns. One thing to clarify at the start: We are a counseling agency, not a financial institution. We cannot refinance your existing mortgage. Nor can we lend you money to cure your mortgage delinquency and bring your mortgage current. Instead, we will help you assess your current financial/housing situation, clarify your housing goals, explain the available options for working with your mortgage company, and explore other options. We may also assist you in working with your mortgage lender. In addition, we may put you in touch with other community resources that could help with your overall financial situation. We will not tell you what you must do. Instead, we help you explore various options, and possible solutions. Ultimately, we let you decide the course of action to follow.

CCOA offers other counseling services, such as budget counseling, debt management program, credit report review sessions, pre-purchase bankruptcy counseling, and various financial education workshops. Though your counselor may discuss these other services with you, you are not obligated to use these, or any other services/resources mentioned to you. The housing counselor conducting your session has been trained and certified according to standards set by the HUD. While our counselors have training in a variety of housing issues, they are not lawyers and cannot provide you with legal advice. You will receive a written Plan of Action upon completion of the counseling session. It will lay out the counselor's recommendations for resolving your mortgage concerns.

Statement of Privacy and Confidentiality

CCOA is committed to maintaining your privacy. All information shared with us will be managed within legal and ethical considerations. We will only release your personal financial information to your mortgage company or creditors with your specific authorization. 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 by using 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.

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.

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

Printed Name:*

Signature Date:*

* fields are mandatory

Fayetteville

1111 E. Zion Road
Fayetteville, AR 72703

Phone: 479-521-8877
Fax: 479-521-9200

Bentonville

1730 SE Moberly Lane, Suite 3
Bentonville, AR 72712

1-800-889-4916

Fort Smith

3200 Rogers Ave
Fort Smith, AR 72901

1-800-889-4916

Terms & Conditions | Privacy Policy

Please provide proof of your identity.

For your protection, in order to complete your credit report review you must provide CCOA with proof of your identity through a valid municipal, state or federal photo ID (driver’s license, passport, etc.)

For phone appointments please email a copy of your ID to contactus@ccoacares.com.
For in person appointments please bring your ID with you to the appointment.
Or upload a copy of your ID using the Credit Report Review Authorization form.

Proceed to Credit Report Review Authorization Form

Proporcione prueba de su identidad.

Para su protección, para completar la revisión de su informe de crédito, debe proporcionar a CCOA una prueba de su identidad a través de una identificación con foto municipal, estatal o federal válida (Ejemplo: Licencia de conducir, pasaporte, etc.)

Para citas telefónicas, envíe una copia de su identificación por correo electrónico a contactus@ccoacares.com
Para citas en persona, traiga su identificación a la cita.

Proceda al formulario de autorización de revisión del informe de crédito-SPANISH

Want to know how soon you'll be debt free?

To ensure your balances are as accurate as possible, please take the time to send us copies of your most recent statements from your creditors. With these statements CCOA can better estimate when you will be debt free! There are three ways to send these statements to CCOA:

Email: contactus@ccoacares.com
Fax: (479) 521-9200
Mail: P.O. Box 10168 Fayetteville, AR 72703.

Proceed to Client Portal

Want to know how soon you'll be debt free?

Email: contactus@ccoacares.com
Fax: (479) 521-9200
Mail: P.O. Box 10168 Fayetteville, AR 72703.

Proceed to Web Payment Form

Education

Housing

Money Management

Personal Information

Contact information

Information on Home Facing Foreclosure/Mortgage Concerns

Current Mortgage (answer us much as you can)

Explain Underlying Cause of your Current Mortgage Problem

Monthly Living Expenses

Creditors

Monthly Household Income(Net-after Taxes,etc.)

Counseling Services Agreement

Statement of Privacy and Confidentiality

Fayetteville

Bentonville

Fort Smith

Education

Housing

Money Management

Education

Housing

Money Management

Personal Information

Contact information

Information on Home Facing Foreclosure/Mortgage Concerns

Current Mortgage (answer us much as you can)

Explain Underlying Cause of your Current Mortgage Problem

Monthly Living Expenses

Creditors

Monthly Household Income(Net-after Taxes,etc.)

Counseling Services Agreement

Statement of Privacy and Confidentiality

Fayetteville

Bentonville

Fort Smith

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