Student Loan Counseling Data Sheet

Personal Information

Contact Information

Monthly Living Expenses

Counseling Services Agreement

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
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
Tithes, Offerings, Charity


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

Please sign below after reading our Counseling Services Agreement which explains the service we are offering

We understand that you are contacting us regarding your student loan concerns. In our experience, consumers struggling with student loans are usually facing one or both of the following problems. They are unaware of the current status of their loans (Amount owed? In default? In collections? Who holds them? What kind are they?), or they don't see how an affordable payment can be set up that will fit in their current budget. Our individualized student loan counseling is designed to help you with these problems. We're able to help you explore the options available, and to get the best information possible on the current status of your loans.

We are a member agency of the National Foundation for Credit Counseling (NFCC). The student loan counselor you will work with has been trained and certified by the NFCC to help you with student loan issues. While our counselors have training in a variety of financial 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 summarize the session and lay out the counselor's recommendations for addressing your student loan concerns.

Our agency offers other counseling services, such as credit report reviews and a debt management plan. Though your counselor may discuss these and other services with you, you are not obligated to use these, or any other services/resources mentioned to you.

In your counseling session, you can expect your counselor to go through the following steps with you:

  • Help you determine your financial goals
  • Compile a budget to give you a picture of your current finances
  • Help you obtain an FSA ID allowing you to access critical account information
  • Assist with collection of your NSLDS file, if you have federal loans
  • Evaluate student loan details and repayment options
  • Provide a series of recommendations on best options
  • Provide an action plan (written summary of session and action steps)

Unlike many of our services, there is a fee for our student loan counseling of $150. We can take payment in cash (exact change appreciated), cashier's check/money order, personal check, debit or credit card. We have pledged to offer our services to clients without regard to your ability to pay. In other words, if you feel the fee would prevent you from using our services, you can apply for a fee waiver. If your documented gross household income is less than 150% of the federal poverty level (adjusted for family size), you may qualify for a fee reduction or waiver.

Credit Counseling of Arkansas pledges you have the right to:

 If you are dissatisfied with any aspect of the service provided, you can utilize the Complaint Resolution Process described below:

  • Step1: I will try to resolve the issue with the staff member involved.
  • Step2: 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.
  • Step3: 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

Credit Counseling of Arkansas is committed to maintaining your privacy. We assure you that all information shared with us will be managed within legal and ethical considerations. It is only with your specific authorization that we release your personal financial information to your creditors and others directly involved in your student loans. 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 through the use of 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.

The following practices govern our efforts to maintain your privacy:

  1. We do not disclose any nonpublic personal information about our clients or former clients to anyone, except as required by law.
  2. We may compile data and information that you give to us, but this information may not be disclosed in a manner that would personally identify you in any way.
  3. We may disclose some or all of the information that we collect, as described below, to creditors, related financial institutions, or third parties that you have authorized who need this information in order for us to assist you. This information is collected from the following sources:
    • From you, on our applications or other forms that you provide, such as your name, address, social security number, assets, and income
    • From your transactions with us, your creditors, and others, such as your account balance & payment history
  4. 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.
  5. Client data sheets are disposed of (shredded) if there is no follow-up contact after approximately six months. Electronic records of appointment dates and counseling notes are maintained electronically, and are not purged.

RELEASE: I authorize Credit Counseling of Arkansas, Inc. to release all nonpublic information it obtains about me to my creditors and any third party necessary to resolve the matters discussed during my counseling session. I also release and authorize all of my creditors to provide nonpublic information about me to Credit Counseling of Arkansas.

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