Pre-bankruptcy application

Disclosure form

Welcome! We understand that you are here because you are experiencing financial problems, and that you are considering filing for bankruptcy and are required to receive “counseling” before you may file. 

This agency has over 34 years of experience of helping people with financial problems. Our goal is not to be judgmental, but to provide assistance. Specifically, we do a budget analysis that will examine your situation, discuss the factors that may be the cause of your problems, and explore your options for developing a reasonable plan for dealing with them. We will provide you with information about bankruptcy, including its process and possible consequences. We will also consider alternatives to bankruptcy to resolve your problems. It is our view that the purpose of this session is to provide you with information so that YOU may chose the option that you think is best. At the conclusion of this session, you will be provided a certificate that you will need should you decide to file bankruptcy. This certificate is valid for up to 180 days after counseling session is completed.

 This agency is a member of the National Foundation for Credit Counseling (“NFCC”). The NFCC has high standards for quality credit counseling and financial education, and this agency complies with those standards. In addition, this agency is accredited by the Council of Accreditation (“COA”), an independent third-party organization that reviews and monitors entities that provide social services. We are a non-profit agency. We are organized and operate in accordance with Section 501c (3) of the Internal Revenue Code.

 The consumer credit counselor conducting or supervising this session has been trained and certified in accordance with the NFCC standards, and while he/she has expertise in helping those with financial problems, he/she cannot provide you with legal advice. In fact 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 essential that you provide us with information that is as accurate and complete as possible. For that reason, we may ask you to authorize us to access your credit history. Rest assured that the information concerning your financial condition and status that you provide during this session is strictly confidential. Such information would include, but not limited to, income, debts, credit accounts, earning, assets, and employment data. We will not disclose any such information that you provide orally or in writing to anyone, except as authorized by you in writing or as required by law, such as in response to a subpoena. We may compile data and aggregate information that you give us, but this information will not be disclosed in any manner that would personally identify you. This agency will not disclose or provide any information about this session to a credit-reporting agency. If you should decide to enter into a Debt Management Program (‘DMP”) (which will be explained in the course of this session) you will be provided with a separate agreement and disclosure forms.

 To help cover the cost of providing this session to you, this agency charges a fee at the time of the appointment in cash or money order of $75.00 made payable to Consumer Credit Counseling Service. In limited circumstances, you may be eligible to have this fee waived.

 This agency also receives funding in the form of grants from entities that support financial counseling such as the United Way, state and federal governmental units, and creditors. A significant portion of funding comes from voluntary contributions from creditors who participate in DMP’s. Since creditors have a financial interest in having debts repaid, most are willing to make contribution to help fund the overall services of this agency. These contributions are usually calculated as a percentage of payments that are made through a DMP. Again, should you decide to enter into a DMP, you will receive specific information on how the plan works and how the agency is funded.

I have read and understood the disclosures made above.

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