Bankruptcy – Pre-Filing Online Disclosure Form – In Person

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We understand that you are contacting us because you are experiencing financial problems, and you may be considering filing for bankruptcy. Before filing for bankruptcy, you are now required to receive credit counseling. You can take the course on the phone , internet or person it is the same fee. We are here to help you fulfill that requirement. Our agency, Credit Counseling Center (CCC) has over 25 years of experience helping people with financial problems. Specifically, we will work with you to create a budget analysis that will examine your financial situation. We will discuss the factors that may be the cause of the financial problems, help you explore your options, and work with you to create a plan for dealing with your financial concerns. We will provide you with some information about bankruptcy, including the bankruptcy process, and some of the possible consequences of bankruptcy. We will also review some of the alternatives to bankruptcy. We believe the purpose of this session is to provide you with information so that YOU may chose the option that you think is best. We have an obligation to issue this certificate promptly upon completion of the course.

Our agency complies with those standards. In addition, our agency is accredited by the Council on Accreditation, an independent, third-party organization that reviews and monitors organizations working in the social service field. We are a not-for-profit agency, organized to operate as a provider of educational services in accordance with Section 501(c)(3) of the IRS code. The consumer credit counselor conducting or supervising your session has been trained and certified according to The National Association of Certified Credit Counselors. While the counselor has been trained to help those with financial problems, s/he is not a lawyer, and 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. You may have the opportunity to negotiate an alternative payment schedule with regard to each unsecured consumer debt under terms as set forth in 11 USC 502(k), we do not provide this service. We do not provide bilingual services or interpreter assistance to any limited English proficient clients. To find an organization that provides these services please go to the US Trustee site at:

In order to assist you, it is important that you provide us with information that is as accurate and complete as possible. You can be assured that the financial information you provide during the session is strictly confidential. Such information would include, but not be limited to, your income, debts, credit accounts, earnings, assets, and employment. We will not disclose any such information that you provide verbally or in writing to anyone, except as authorized by you in writing, or as required by law, such as in response to a subpoena or to the United States Trustee in their oversight of this agency or during the investigation of complaints, during on-site visits or during quality service reviews. We may compile and group data that you give us, but this information will not be disclosed in any manner that would personally identify you. CCC will not disclose or provide any information about this session to a credit reporting agency. This agency has a policy of prohibiting it from paying or receiving referral fees for the referral of clients. No fees are either paid or received by our agency for the referral of a client to an attorney or any bankruptcy alternative agency. The United State Trustee has reviewed only our credit counseling and personal financial management instructional course pursuant to 11 U.S.C. 111(d) and the US Trustees has neither reviewed or approved any other services we provide to clients. One option we may discuss with you is the use of a Debt Management Plan (DMP). If you decide to make use of a DMP, you will be provided with separate agreement and disclosure forms. You should be aware that bankruptcy could have a severe impact on your credit standing. A DMP can also affect credit, either favorably or unfavorably, according to your creditors’ policies regarding the DMP, and your payment history prior to and during the DMP.

There is a fee of $39 per session (person or married couple) for this service. We do not charge an additional fee for the generation of the certificate. We can take payment in cash (exact change appreciated), cashier’s check/money order, personal check, or online payment. A waived fee is based on 150% of poverty guidelines updated periodically by the US Department of Health and Human Services. CCC will provide services without regard to a client’s ability to pay (fee waiver policy). In addition to the client fees, CCC also receives funding in the form of grants from HUD and certain financial institutions. Should you decide to utilize a DMP, you will receive separate information on how the plan works.

We are required to verify that the person counseled is the person in whose name the certificate is issued. In other words, no “stand-ins” for counseling sessions. For this reason, you will be asked to provide some form of photo identification at an in-person counseling session. If your session is conducted by phone, you will be asked when you schedule the appointment to provide some form of unique personal information, such as mother’s maiden name, favorite color, or last four digits of your social security number. Your counselor will verify that information at the time of the counseling session.

By submitting this data sheet, you are acknowledging that you have read and understood the disclosures made above. Submitting this form also serves as an affidavit, certifying that the information you provide is accurate, complete, and made in good faith. Your submission of this form will also certify that the person(s) participating in the counseling session is the person whose name will appear on the certificate to be issued.