Please read the following statements carefully so that you will understand the procedures for the counseling session. Initial the line next to each statement to indicate understanding of that provision. For simplification the singular is used even when the plural may apply. Consumer Credit Counseling Service is referred to as CCCS and the agency. 

_____ I understand the agency will provide a confidential comprehensive personal money management interview.

_____ I understand that the interview will be conducted by a certified consumer credit counselor or qualified professional counselor.

All action plans, not conducted by a certified consumer credit counselor, will be reviewed by a certified consumer credit counselor.

_____ I understand, that in the event we are dissatisfied, I can utilize the Complaint Resolution Process.

_____ I understand that most of the agency funding comes from voluntary contributions from creditors who participate in the Debt Management Program (DMP).

Since creditors have a financial interest in getting paid, most are willing to make a contribution to help fund CCCS.  These contributions are usually calculated as a percentage of payments you make through your DMP, up to fifteen percent (15%) of each payment received. However, your accounts with your creditors are to be credited with one hundred percent (100%) of the amount you pay through CCCS and CCCS will work with all your creditors regardless of whether they contribute to the agency. If you see any discrepancy between the payment CCCS sent and the amount posted on your statement, please bring it to the agency s attention immediately and the matter will be promptly addressed.

_____ I hold the agency, its employees, agents and volunteers harmless from any claim, suit, action or demand of my creditors, myself or any other person resulting from advice or counseling.

_____ I will be given a written assessment outlining a suggested client action plan which will be based on the following options:

a.) I will handle any financial concerns on my own.

b.) I may choose to enroll in the Debt Management Program (DMP). The DMP serves the dual role of helping you repay your debts and helping creditors to receive the money owed to them.

My participation in a debt repayment program may change information which is already on my credit report. If my credit report reflects that I have paid creditors as agreed in the past, a Debt Management Program could have a negative impact on a credit worthiness decision by potential creditor, landlord, or employer in the future.  In addition, creditors may report that I am on a Debt Management Program and am not paying as originally agreed although they have accepted the reduced payment.

c.) You should also be aware that debts to creditors you repay through the plan may be able to be discharged through bankruptcy. Counselors cannot provide legal advice.

d.) I will be referred to other services of the organization or another agency or agencies as appropriate that may be able to assist with particular problems that have been identified.

_____ At sometime in the future, my information may be used for confidential research and/or a neutral third party may contact me to request an evaluation of the agency's services.

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Applicant/Date                                          Co-applicant/Date                                          Counselor/Date