Personal Information

Contact information

Home Facing Foreclosure

Monthly Living Expenses

Counseling Services Agreement

Personal Information


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Contact information



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Information on Home Facing Foreclosure/Mortgage Concerns


Current Mortgage (answer us much as you can)


Explain Underlying Cause of your Current Mortgage Problem


Please explain the underlying causes of your current mortgage problems:

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.

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

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

Identity Verification We are required to verify that the person counseled is the person in whose name the certificate is issued. In other words, no “stand-ins” for counseling sessions. For this reason, you will be asked to provide some form of photo identification at an in-person counseling session. If your session is conducted by phone, you will be asked when you schedule the appointment to provide some form of unique personal information, such as mother’s maiden name. Your counselor will verify that information at the time of the counseling session. Your signature on the following page (“Disclosure Form”) will serve as an affidavit certifying that the information you provide on this form is accurate, complete, and made in good faith. Also, your signature will certify that the person(s) participating in the counseling session is the person whose name will appear on the certificate to be issued.

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


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

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 a credit report review and a debt management plan. 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 National Foundation for Credit Counseling. 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:
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