For an appointment, please complete the following forms. PLEASE NOTE: There are 5 pages to this form. Please review each form thoroughly and complete all applicable spaces. The information will be forwarded to our agency and you will then be contacted to set up an appointment.


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Budget Information Worksheet

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STATEMENT OF COUNSELING SERVICES
Please read the following statements carefully so that you will understand the procedures for the counseling session. Check the box next to each statement to indicate understanding of the provision. For simplification, the singular is used even when the plural may apply.

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

I understand that the fees for a pre-filing bankruptcy session are $50 for an individual or $75 for a couple attending the same session.

I understand that if my household meets low-income guidelines, the fee will be waived and the agency will provide services.

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 most of the agency funding comes from voluntary contributions from creditors who participate in Debt Management Plans (DMP). Since creditors have a financial interest in getting paid, most are willing to make a contribution to help fund our agency. 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 will always be credited with one hundred percent (100%) of the amount you pay through us. We will work with all your creditors regardless of whether they contribute to our agency.

I will be given a written assessment outlining a suggested client action plan which will be based on the following options: I will handle any financial concerns on my own I may choose to enroll in the agency's debt management plan. I realize the DMP is only one of several options and is not suitable for all clients. Our DMPs serve the dual role of helping you repay your debts and helping creditors to receive the money owed to them. Once money is deposited with our service, it becomes the property of your creditors. If I choose to enroll in a DMP, I agree not to open any new credit accounts or incur any additional debt. While the agency may obtain a credit report and/or inform any credit reporting agency of my participation in the repayment plan, the agency has no responsibility or obligation for any past, present, or future credit rating I receive. In certain circumstances, a debt management plan may affect my credit rating negatively. In the event that the counselor suggests a debt management plan, I will receive complete details of the operations, requirements, responsibilities, and DMP fees. A counselor may answer any questions about bankruptcy, but not give legal advice. If I want legal advice, I will be referred for appropriate assistance. While an attorney can make a recommendation to file bankrupcty, it is a personal choice based on individual circumstance. 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.

I understand that in the event that I am dissatisfied, I can utilize the Complaint Resolution Process on the next page.

By checking "Agree" below, I certify that I have read, checked, and agree to all of the above statements.

Agree

Disagree

Please be sure to read all of the ABOVE statements and check the boxes next to EACH statement.

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Client Bill Of Rights

We pledge that our clients have the right:

• To prompt counseling services for managing money based on their financial situation.
• To treatment with dignity and respect;
• To be actively involved in a comprehensive assessment of their financial situation including an appropriate action plan;
• To express dissatisfaction through a Complaint Resolution Process;
• To discontinue their relationship with our agency at any time;
• To ask questions and to have concerns addressed.

Complaint Resolution Process 

• Step One: Try to resolve the issue with the staff member involved giving him or her specific information about your complaint.
• Step Two: If Step One is not possible or the issue is not resolved to your satisfaction, contact Jeff Witherspoon, Executive Director, in the Salina Operation's office, 785-827-6731 or in Wichita at 316-265-2000.
• Step Three: Agency may request a meeting with you (telephone or face to face) or seek more information from a staff person. The agency will respond within 15 days.
• Step Four: If your issue is still unresolved, you may appeal in writing directly to the Chairperson for the Board of Directors. After additional fact finding, this individual will provide a concluding decision to you within 15 days.

Non-Discrimination Policy

Our agency serves all members of the community. We do not engage in the practice of discrimination in the selection and participation of clients in our programs or services with respect to race, religion, color, gender, national origin or handicap.

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PRIVACY POLICY: Our agency is committed to assuring the privacy of individuals and/or families who have contacted us for assistance. We assure you that all information shared both orally and in writing will be managed within legal and ethical considerations. Your 'personal financial information', such as your total debt information, income, living expenses, and personal information concerning your financial circumstances, will be provided to creditors and, possibly others with your specific authorization.
We may also use aggregated case file information for the purpose of evaluating our services, gathering valuable research information and designing future programs. Your anonymity will be maintained through the use of your client number or by using aggregate data in all circumstances.

In all other situations, your information may be released to appropriate individuals or agencies ONLY UPON YOUR WRITTEN REQUEST OR when our staff has been served by a valid subpoena.

The following PRIVACY PRACTICES detail circumstances under which we will release your information to a third party:

1.      We do not disclose any nonpublic personal information about our customers or former customers to anyone, 
         except as permitted by law.

2.      We may compile data and aggregate 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, or third parties
          that you have authorized who need this information in order for us to assist you after a counseling session.

4.      We may disclose all of the information that we collect, as described below, to creditors and related financial
         institutions who need this information in order to put you on a Debt Management Plan (DMP).

5.      We restrict access to nonpublic personal information about you to those employees who need to know that 
         information to provide services to you. We maintain physical, electronic and procedural safeguards that comply 
         with federal regulations to guard your nonpublic personal information.

6.      We collect nonpublic personal information about you from the following sources:

• Information we received from you on our applications or other forms you provide;
• Information about your transactions with us, your creditors, or others; and
• Information we receive from a credit reporting agency.

7.      We may disclose the following kinds of nonpublic personal information about you:

• Information we receive from you on applications or other forms, such as your name, address, social security number, assets, and income,
• Information about your transactions with us, your creditors, or others, such as your account balance, payment history, parties to transactions, and credit card usage; and
• Information we receive from a credit reporting agency, such as your credit history.

RELEASE: I hereby authorize the Credit Counseling Agency to release all non-public information it obtains about me to (1) my creditors and (2) any third parties necessary to resolve the matter(s) discussed during my counseling session.

I further RELEASE and authorize all of my creditors to provide non-public information about me to the Credit Counseling Agency.

 By checking "Agree" below, I certify that I have read and agree to all of the above statements.

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As a HUD Certified Housing Counseling Agency, Consumer Credit Counseling Service, Inc. is required to collect Race and Ethnic Data. Please complete the following. Thank You.

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