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 non-public 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 to creditors, or third parties that you have authorized who need this information in order for us to assist you during and after a counseling session. 
4. We restrict access to non-public 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 non-public personal information. 
5. We collect non-public 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.
6. We may disclose all of the information that we collect, as described below, to creditors and related financial institutions that need this information in order to put you on a debt management plan (DMP.)
7. We may disclose the following kinds of non-public 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 Consumer Credit Counseling Service of Forsyth County and Consumer Credit Counseling of Denver 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 Consumer Credit Counseling Service of Forsyth County and Consumer Credit Counseling of Denver.

AGREEMENT FOR COUNSELING SERVICES  

Please read the following statements carefully so that you will understand the procedures for the counseling session.  For simplification the singular is used even when the plural may apply.   

• I understand that Consumer Credit Counseling Service of Forsyth County, Inc. (hereafter referred to as "agency") will provide a confidential comprehensive personal money management interview for the purpose of qualifying for a bankruptcy certificate. 
• I understand that the interview will be conducted by a counselor certified to provide bankruptcy, housing and credit counseling. 
•  I understand that upon completion of the counseling session, I will be provided a Bankruptcy Certificate which is valid for 180 days (6 months) and may be used to file for bankruptcy. 
• I understand that in the event that I am dissatisfied, I can utilize the Complaint Resolution Process. 
•  I hold the agency, its employees, agents and volunteers harmless form any claim, suit, action or demand of my creditors, myself or any other person resulting from any advice or counseling.  

1. A counselor  may answer questions about Bankruptcy, but not give legal advice.  If I want legal advice, I will be provided with a list of attorneys.  
2. I will handle any financial concerns on my own. 
3. I may choose to enroll in the agency's Debt Management Plan (DMP).  I understand there will be fees associated with setting up and maintaining a DMP.  In the event that the counselor suggests a DMP, I will receive complete details of the operations, requirements, and responsibilities.  Under the DMP, the agency serves as a neutral third party in negotiating with the creditors to liquidate financial obligations.  While the agency seeks to negotiate repayment terms advantageous to my credit rating, the agency has no responsibility or obligation for any past, present, or future credit rating I receive. 
4. I will be referred to the 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.  

• I authorize the agency to disclose financial information, including, but not limited to income, debts, assets, and etc. to any creditor or other party listed by me or identified by my counselor, and to gather whatever financial information the agency deems necessary from the creditors and other pertinent agencies working on my behalf.
• I understand that the non-profit receives its funding from a variety of sources, community, clients, creditors, government, etc.  There is a $50.00 fee for my bankruptcy certificate counseling session.  The agency reserves the right to waive or lower fees at the discretion of the agency based on the clients financial need.
• At sometime in the future, a neutral third party may contact me to request a confidential evaluation of the service.  

NON-DISCRIMINATION POLICY:   Our agency serves all members of the community.  We do not engage in the practices of discrimination in the selection and participation of clients in our programs or service with respect to ability to pay, race, religion, color, gender, sexual preference, national origin, or handicap.

Notice to Clients Who Desire a Bankruptcy Certificate:   Our Counseling Service toward Bankruptcy Certificate is a program designed to help clients meet the requirements of declaring Bankruptcy under the October 17, 2005 Bankruptcy guidelines.  Upon completion of a Bankruptcy Counseling session, the client is provided a certificate, which is valid for 180 days (6 months) from date of issue.  If your credit report is pulled for counseling, it may or may not affect your credit score.  CCCS Counselors are certified to provide bankruptcy, credit and housing counseling through the National Foundation for Credit Counseling (NFCC).  Bankruptcy counseling provides information about bankruptcy and its alternatives so the client can make an informed decision.  CCCS counselors do not provide legal advice, but can provide a list of attorneys to the client upon request.  The fee for Bankruptcy Counseling is $50.  Fees for Bankruptcy Pre-Discharge Debtor Education are $30 individual, $40 couple filing jointly.  CCCS Forsyth reserves the right to lower or waive fees based on financial need.  CCCS Forsyth receives additional operational funding through grants, gifts and other contributions from non-profit organizations, government agencies, businesses, and individuals.  CCCS Forsyth is a member of the National Foundation for Credit Counseling, Inc.®, the Council on Accreditation, and is a United Way Partner Agency.

If requested, I authorize CCCS of Forsyth County to release a copy of my Bankruptcy Certificate to my attorney and will provide the attorney's name, address and fax # if needed.  

I have read and agree to the above listed terms, conditions and counseling fees.

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