Disclosure Form

Personal Information

Contact Information

Joint Account Holders

Monthly Living Expenses

Disclosure Form for Pre-Filing Bankruptcy Clients


We understand that you are contacting us because you are experiencing financial problems, and you are considering filing for bankruptcy. Before filing for bankruptcy, you are required to receive credit counseling.

Our agency, Credit Counseling of Arkansas (CCOA), has extensive experience helping people with financial problems. Our role is not to judge you, but to provide information and assistance. We will help you create a budget analysis to examine your financial situation. We will discuss the factors that may be the cause of the financial problems, help you explore your options, and work with you to create a plan for dealing with your financial concerns. We will provide you with some information about bankruptcy, including the bankruptcy process, and some of the possible consequences of bankruptcy. We will also review some of the alternatives to bankruptcy. The purpose of this session is to provide you with information so that YOU may choose the option that you think is best. After the completion of the counseling session, we are obligated to promptly provide you with a certificate that you will need if you decide to file for bankruptcy. The certificate is valid for 180 days from the date of the counseling session and will only be issued at the completion of the counseling session.

CCOA is accredited by the Council on Accreditation, an independent, third-party organization that reviews and monitors social service organizations. We are a not-for-profit agency, operating as a provider of educational services in accordance with Section 501(c)(3) of the IRS code. We are approved by the Executive Office of U.S. Trustee (EOUST) to provide pre-filing bankruptcy counseling and post-filing debtor education and issue certificates in compliance with the Bankruptcy Code, this approval is not an endorsement of the agency's other services.

CCOA has English and Spanish speaking counselors available to conduct your session. Though trained to help you assess financial problems, your counselor is not a lawyer, and cannot provide you with legal advice. This session is designed to provide you with information and alternatives; it is not intended to take the place of a consultation with an attorney to explore your legal rights and options.

In order to assist you, it is important that you provide us with information that is as accurate and complete as possible. Be assured that the financial information you provide during the session is strictly confidential. Such information would include, but not be limited to, your income, debts, credit accounts, earnings, assets, and employment. We will not disclose any such information that you provide verbally or in writing to anyone, except as authorized by you in writing, or as required by law, such as in response to a subpoena or as required in an EOUST quality review. We may be required to disclose debtor information to EOUST in connection with their oversight of our company's services, during an investigation of any inquiries, during on-site visits, and during quality of service reviews. We may compile and group data that you give us, but this information will not be disclosed in any manner that would personally identify you. CCOA will not disclose or provide any information about this session to a credit reporting agency. One option we may discuss with you is the use of a Debt Management Plan (DMP). If you decide to make use of a DMP, you will be provided with separate agreement and disclosure forms. You should be aware that bankruptcy could have a negative impact on your credit report for 7 to 10 years. A DMP can also affect credit, either favorably or unfavorably, according to your creditors' policies regarding the DMP, and your payment history prior to and during the DMP. Clients on their own or through CCOA services, have the right to negotiate an alternative payment schedule with regard to each unsecured consumer debt.

There is a fee of $50 per session for the bankruptcy pre-filing counseling. We can take payment in cash, cashier's check/money order, personal check, or debit card. CCOA will provide services without regard to a client's ability to pay. If your household gross income is less than 150% of the poverty guidelines provided by the U.S. Department of Health and Human Services, you may be eligible for a full or partial fee waiver. You will need to complete a Fee Waiver form and provide documentation of household income.

We prohibit payment or receipt of referral fees. CCOA receives funding from client fees and grants, as well as funding from some financial institutions. A significant portion of our agency funding comes from creditors who participate in DMPs and provide us with voluntary contributions. Since creditors have a financial interest in having debts repaid, many are willing to make a contribution to help the overall services of this agency. These contributions are usually calculated as a percentage of payments that are made through a DMP. Should you decide to utilize a DMP, you will receive specific information on how the plan works, and how the agency is funded.

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

Personal Information


Family Information



* fields are mandatory

Contact Information


Joint Account Holders


(Any person other than you or a spouse, whose name appears on any creditor statement)

Assets Information:


Please answer as completely as possible. We do not share your information
with any outside agencies. You may elect to provide this information with your bankruptcy attorney. S/he will help you complete the necessary forms and schedules if you decide to file for bankruptcy. Round off figures to the closest dollar amount.

Assets Value
CASH & CASH EQUIVALENTS
Checking account balances
Savings account balances
Certificates of Deposit
Other
HOUSEHOLD GOODS**
Furniture
Jewelry
Computers
Home Entertainment(audio, visual)
Tools
Valuable Collections
Assets Value
INVESTMENTS (NON-RETIREMENT)
Mutual Funds
Stocks
Bonds
Savings Bonds
RETIREMENT FUNDS
IRAs
401K
403B
SEP / SIMPLE
Company Retirement Plans
Assets Value Owed
REAL PROPERTY
Home (current market value)
Land
Vehicle 1 ##
Vehicle 2
Vehicle 3
Motorcycle / ATV
RV / Airplane

** Estimate the value of Household Goods based on what would be raised if they were sold on short notice -- not based on the maximum possible sale price.

Monthy Net Income:


Applicant Income Co-Applicant Income Child Support Retirement Other Income
TOTAL MONTHLY NET INCOME: $

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

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

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

MONTHLY LIVING EXPENSES Currently
Personal Property Taxes

/month

Dry Cleaning, Laundromat

/month

Tobacco, Alcohol

/month

Entertainment, Vacations

/month

Clothing

/month

Tuition, Books, Supplies, Lessons

/month

Barber, Beauty

/month

Streaming Services

/month

Bank Fees, Overdraft Charges

/month

Pets, Veterinarian

/month

Retirement Savings

/month

Emergency Fund Savings

/month

Quarterly Income Taxes

/month

Car Registration, Tags

/month

Home Repair

/month

Club Dues

/month

Gifts (Christmas, birthdays, other)

/month

Household Items (Linen, Kitchen Items)

/month

Children's Allowances

/month

Lawn Service / Pest Control

/month

Cosmetics

/month

Postage

/month

Tithes, Offerings, Charity

/month

Creditor:


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

$

$

You can add more rows by clicking the "Add Row" button below.

$

$

$

$

$

$

$

$

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 your date of birth. Your counselor will verify that information at the time of the counseling session. Your signature on the first 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.