Please read the following statements carefully so that you will understand the provisions of the Debt Management Program. Initial the line next to each section to indicate your understanding of that provision.
For simplification the singular is used even when the plural may apply.

I engage the professional services of Consumer Credit Counseling Services of Northeastern Pennsylvania, Inc. (CCCS) to provide debt management counseling services in negotiating a repayment plan hereinafter referred to as the Debt Management Program or "DMP" with my creditors. I freely volunteer to abide by the provisions of this agreement, which are as follows:

I understand that I am responsible for disclosing to the agency accurate information, to the best of my knowledge, about all of my creditors and sources of income. In consideration of and in furtherance of services to be provided by CCCS I hereby expressly authorize the agency, its employees, agents/volunteers to:

  1. Disclose any information concerning my financial condition and status, including but not limited to income, debts, credits, earnings, assets, and residential and work addresses to creditor(s) listed by me unless otherwise required by law, and;
  2. Obtain whatever financial information concerning me from any creditors, as agency deems necessary and;
  3. May obtain a copy of my credit report in order to enable CCCS to better assess my financial situation and thereby increase its ability to assist me in the liquidation of my debt. I understand that said credit report will be the sole property of CCCS and I will not receive a copy of my credit report. All information contained in the credit report will be considered confidential and used for legitimate business purposes under the Fair Credit Reporting Act.
  4. Use a third party to transfer my funds and to receive/send information about my account to/from my creditors.

    I agree that a minimal, non-refundable set-up fee of $25.00 will be required to start the DMP. I understand that a monthly maintenance fee of $18.00 will be charged on my account to cover DMP processing. No one will be denied enrollment in the DMP because of an inability to pay the monthly maintenance fee.

    I agree to deposit with CCCS of NE PA, Inc. my monthly debt payments as negotiated by the CCCS. I agree to make all deposits by electronic transfer (ACH) certified check, money order made payable to CCCS of Northeastern Pa, or debit card. I understand that CCCS will not accept cash or personal checks. For the purpose of the accounting for and the disbursal of funds, I expressly agree to permit the agency to combine my funds with the funds of other clients being serviced by the agency in Deposit Account.

    With respect to my credit history, I understand that 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 Plan could have a negative impact on a creditworthiness decision by a potential creditor, landlord, or employer in the future.

    With respect to additional creditor charges and duration of the DMP, I understand that estimated finance charges, fee or penalties imposed by creditors may increase my overall indebtedness as well as the length of time required to fully pay my creditors over and above the estimates provided by CCCS. I further understand that increasing my DMP payment may have a favorable impact on these charges, reducing the amount of time estimated to achieve completion of my DMP. Therefore, as it is in my best interest, I will make every effort to increase my deposit wherever possible. CCCS will provide as precise an estimate as possible for the duration of the DMP.

    With respect to re-aging an account while on the DMP, I understand that the Federal Financial Institution Examination Council (FFEIC) permits institutions to re-age an open-and account that has entered into a workout program after receipt of three (3) monthly payments or the equivalent cumulative amount. Re-aging open-end accounts for workout program purposes is limited to once in a five (5) year period and is in addition to the existing once-in-twelve-months/twice-in-five-years limitation.

I have read and understand the agreement above, check box and continue below.

Termination of Agreement:

  1. I understand that CCCS reserves the right to discontinue my Debt Management program if I fail to make two (2) consecutive monthly payments in full or I make more than four (4) partial payments in a year's time totaling less than 50 percent of my required deposit, Creditor cooperation depends on consistent payments through the agency. A Debt Management Program cannot be re-opened without re-counseling.
  2. I understand that this agreement can be terminated immediately by CCCS if it is found that I have pro vided any false information to this agency, or I have paid creditors on my own, or if I fail to comply with any other provisions, terms or conditions of this agreement. I understand that I can terminate this agreement for any reason by providing written notice to agency. If this agreement is terminated by the agency or me, any money left in my account will be paid to my creditors, unless otherwise requited by law. I understand that if my DMP is terminated, it is our responsibility to notify my creditors.
  3. I understand that my creditors voluntarily cooperate with CCCS in this repayment program. I further understand that if I miss one or more payments or make partial payments, or for any other reason they deem appropriate, my creditors reserve the right to discontinue any concessions made to me under the DMP with respect to interest, penalties, and fees.

Other provisions:

  1. CCCS agrees to send me periodic statements of payments made through the agency. I agree to monitor my statements from creditors to verify that payments have been received and to notify this agency of significant differences between the balances on my creditor statements and agency statements. I understand that I have the right to review my file in the presence of an agency staff member during regular business hours.
  2. I understand that though a counselor may answer questions about bankruptcy, CCCS does not provide legal advice. If legal advice is needed, I will seek the appropriate assistance.
  3. I understand that CCCS in its discretion may make changes to this agreement including increases in monthly service charges, by giving me thirty (30) days notice.
  4. I understand that authorized agency staff or staff agencies with legitimate authority to monitor agency practices may review my file for quality assurance or compliance purposes. If such a review should occur, I understand that the findings will be kept confidential.
  5. I hereby agree to hold CCCS of NE PA, Inc., its employees, officers, directors and agents harmless from any claim, suit, action or demand made by any of my creditors and any other person, which in any manner may arise from any action or inaction taken by this agency, or my creditors, in connection with any services rendered by the agency for me. Nothing herein shall apply to actions or claims under the provisions of the United States Bankruptcy Code, 11 U.S.C. 101 ct seq.
I have read and understand the agreement above, check box and continue below.

Usage of credit:

I hereby certify that all of my credit cards have either been returned to the creditor, lost, destroyed or turned into CCCS for disposal. I voluntarily agree that no further charges will be made on the accounts. In the event that there is no balance on an account, I will request that the creditor close the account. I further understand and agree that I will not apply for, nor will I ask anyone for more credit or assume any new debts without prior agency approval.

I acknowledge that I have read and understand each of the above provisions, terms, and conditions of this agreement. Both CCCS and I have received a copy of this agreement. CCCS of NE PA, Inc. and I agree that there are no other agreements, promises, or representations, unless executed in writing between agency and me other than those contained in this agreement. Please print a copy of this for your records.


If you do not check the boxes above, indicating acknowledgement of the provisions and policies fortified by this agreement, you will not be able to proceed to the next step of this process, and will be returned to the main page of the site.