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To receive counseling services you must read, sign and return the
Statement of Counseling
Services (click & copy this page) and the
Privacy Notice
(click & copy this page) along with
this Financial Worksheet form below to Consumer
Credit Counseling Service of Coos-Curry, Inc. by fax, in person or by mail. You
will need to schedule an appointment time by calling (541) 267-7040 or
(800) 248-7040.
Fax Number: 541-267-7044
Mailing Address:
CCCS of Coos-Curry
375 S. 4th St., Suite 100
Coos Bay, OR 97420
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Please fill out
the form completely. Make an extra copy to keep for your
records.
You may complete the form on the screen and then
print it;
or, print it first and complete it in ink.
GENERAL INFORMATION FORM
1. Last Name
First Name
Middle/Maiden
Single, Married, Widowed, Divorced, Separated
# of Dependants
Rent or Own Home
Birth Date
Social Security
Address
City, State, Zip
Residential Phone Cell Phone
Income Per Month
Gross Pay, Monthly Take Home
Pay, Monthly
Weekly Biweekly Semimonthly Monthly
Deductions from pay (other than taxes; e.g. insurance/savings) $
Employer Position
How long employed? Telephone
Other Income/Source
2. Co-Applicant Last Name
First Name Middle/Maiden
Birth Date Social
Security
Address City, State, Zip
Residential Phone Cell Phone
Income Per Month
Co-Applicant Gross Pay, Monthly Take Home
Pay, Monthly
Weekly Biweekly Semimonthly Monthly
Deductions from pay (other than taxes; e.g. insurance/savings) $
Employer Position
How long employed? Telephone
Other Income/Source
IMPORTANT NOTICE: READ BEFORE SIGNING
Consumer Credit Counseling Service (CCCS) offers a variety of programs to address the
resolution of credit problems. COMPLETION OF THIS WORKSHEET DOES NOT AUTOMATICALLY
GUARANTEE PARTICIPATION IN A DEBT MANAGEMENT PROGRAM. Another option or resource may better
suit your needs.
CCCS does not report participation in a DEBT MANAGEMENT PROGRAM TO CREDIT REPORTING
AGENCIES. CCCS has no control over the credit reporting practices of your creditors. Your
involvement in a program may ADVERSELY affect your CREDIT REPORT.
CLIENT STATEMENT
Everything that has been stated in this worksheet is complete and correct to the best
of my knowledge. I agree to hold Consumer Credit Counseling Service, its employees,
officers and agents harmless from any claim, suit, action or demand of my creditors,
myself, or any other persons as a result of this counseling.
Signature
Signature
Financial Records
Assets
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