Personal Information

Contact Information

Joint Account Holders

Monthly Living Expenses

Disclosure Form

Personal Information


Name: *
Gender:
Date of Birth:

If married, 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: $

Attachment:


Please attach your proof of income documents. (file size limit 5M)

  

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
Medical, Prescription Drugs
Gasoline
Car Maintenance & Repair
Car Insurance
Health, Life Insurance
Homeowner's, Renter's Insurance
Real Estate Taxes
MONTHLY LIVING EXPENSES Currently
Personal Property Taxes
Dry Cleaning, Laundromat
Tobacco, Alcohol
Entertainment, Vacations
Clothing
Tuition, Books, Supplies, Lessons
Barber, Beauty
Newspaper, Magazine Subscriptions
Bank Fees, Overdraft Charges
Pets, Veterinarian
Retirement Savings
Emergency Fund Savings
Quarterly Income Taxes
Car Registration, Tags
Home Repair
Club Dues
Gifts (Christmas, birthdays, other)
Household Items (Linen, Kitchen Items)
Children's Allowances
Lawn Service / Pest Control
Cosmetics
Postage
Tithes, Offerings, Charity

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

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 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.

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. At the conclusion of the session, we will 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.

Our agency is a member of the National Foundation for Credit Counseling (NFCC). The NFCC has high standards for quality credit counseling and financial education. Our agency complies with those standards. CCOA is also 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 education. EOUST approval is not an endorsement of overall agency services.

The consumer credit counselor conducting or supervising your session has been trained and certified according to NFCC standards. 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 severe impact on your credit standing. 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.

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: