Personal Information


Welcome. We understand that you are experiencing financial problems and that you may be considering filing for bankruptcy and that you are required to receive counseling before you file for bankruptcy. CCCS has been approved by EOUST to provide bankruptcy counseling. EOUST has reviewed only the counseling services related to bankruptcy, and the agency may disclose information to them at their request.

CCCS of Northeastern Pa. has over 35 years of experience in helping people with financial difficulties. Our role is not to be judgmental, but to provide assistance to you. Specifically, we will do a budget analysis that will examine your financial situation, discuss the factors that may be the cause of your problems and explore options for developing a reasonable plan for dealing with them. We will provide you with information about bankruptcy, including its process and possible consequences. We will also provide alternatives to bankruptcy. It is our view that the purpose of this session is provide you with the information so that you may choose the option that you think is best. At the conclusion of this session, you will be provided with a certificate within one (1) business day that you will need should you decide to file for bankruptcy. The certificate is valid for up to 180 days of completing counseling. No certificate can be issued if a full counseling session isn’t completed.

CCCS of Northeastern Pa. is a member of the National Foundation for Credit Counseling (“NFCC�). The NFCC has high standards for quality credit counseling and financial education. We are accredited by the Council on Accreditation (“COA�), an independent third-party organization that reviews and monitors social service agencies. We are a non-profit agency in accordance with Section 501 (c) (3) of the IRS code.

The credit counselor conducting or supervising this session has been trained and certified in accordance with NFCC standards. Our counselor has expertise in helping those with financial problems but they cannot provide you with legal advice. 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.

In order to assist you, it is essential that you provide us with information that is accurate. For that reason, we may ask you to authorize us to access your credit history. Please be assured that any information concerning your financial condition that you provide during the session will be held in the strictest confidence. Such information would include, but it not limited to, income, debts, credit accounts, earnings, assets and employment data. We will not disclose any such information that you provide orally or in writing to anyone, except as authorized by you in writing or as required by law, such as in response to a subpoena. We may compile data and aggregate information that you give us, but this information will not be disclosed in any manner that would personally identify you. We will not disclose or provide any information about this session to a credit-reporting agency.

To help cover the cost of providing this counseling session to you, CCCS of Northeastern Pa. charges a fee of $50.00. An adjustment in the required fee will be provided to any client whose income is under 150% of the Federal Poverty Guidelines. You should contact CCCS of Northeastern PA, Inc to determine eligibility.


  • I understand that Consumer Credit Counseling Service of NE PA, Inc. (CCCS) 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 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 your 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 our agency. These contributions are usually calculated as a percentage of payments you make through the 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 and we will work with all your creditors regardless of whether they contribute to CCCS.
  • I hold CCCS of NE PA, its employees, agents and volunteers harmless from any claim, suit, action or demand of my creditors, myself or any other person resulting from advice of counseling. Nothing herein shall apply to actions or claims under the provisions of the United States Bankruptcy Code, 11 U.S.C. 101 et seq.
  • 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 my financial concerns on my own.
    • b.) A counselor may answer 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 recommendation to file bankruptcy, it is a personal choice based on individual circumstances. I will inform the agency of the decision if I file bankruptcy
    • c.) I will be referred to the other services of CCCS or another agency or agencies as appropriate that may be able to assist with particular problems that have been identified.

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 have their concerns addressed.

Complaint Resolution Process

We are committed to providing you with high quality professional service. However, if you are not satisfied with the services provided or you want to make a complaint, we ask that you follow these guidelines.

-- 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, write or call the Vice President at (800) 922-9537 or (570) 602-CCCS.
-- Step Three: CCCS of NE PA may request a meeting with you (phone 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 President of CCCS of NE PA, Inc. After additional fact finding, the President will provide a concluding decision to you within 15 days.

Non-Discrimination Policy

CCCS of NE PA, Inc. 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, age, color, gender, national origin, or handicap.

CCCS OF NE PA INC 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 clients or former clients 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 Program (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 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 Consumer Credit Counseling Service of NE PA, Inc. 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 NE PA, Inc.

By filling out this form, you agree to our terms and conditions.

Last Name:

First Name:


Email Address:

Date of Birth:

Social Security Number:

Spouses Last Name:

Spouses First Name:

Spouses Middle/Maiden:

Spouses Date of Birth:

Spouses Social Security Number:

Current Address No/Street:




Home Phone:

Previous Address No/Street:




Home Phone:

Income Per Month

Gross Pay (Monthly):

Take Home Pay (Monthly):

Total each pay period: $


Position Rank:


Gross Pay (Monthly):

Take Home Pay (Monthly):

Total each pay period: $


Position Rank:

Instructions: List current balances and account numbers for all debts. If you need additional space, please use a seperate sheet.

Please bring your most recent statements with you.

CreditorAccount ##Secured (Y/N)Current Balance## Months DelinquentMonthly Payment

Instruction: Fill in your estimate monthly expenses in the column marked "estimate". For your expenses, use recent monthly bills to average your expenses.

Monthly Living Expenses


Second Mortgage

Renter/Homeowner Insurance

Car Paymnet ##1

Car Paymnet ##2

Child Care

Tax Installments

Child Support/Alimony


Total Fixed Expenses

Flexible Expenses


Meals Out

School Lunches


Oil/Gas/Coal/Other Heating



Family Clothing

Occupational Expenses

Dry Cleaning/Laundry

Home Cleaning Supplies


Bus Fares/Parking/Subway

Diapers/Formula/Baby Supplies



Hair/Personal Care





Baby Sitter

Hobbies/Club Dues






Pet Care

Home Maintenance

Cable T.V.




Total Variable Expenses

Periodic Expenses

Property Taxes

Life Insurance

Health & Accident Insurance

Auto Insurance

Auto Tags/Inspection

Car Maintenance/Oil/Lube/Tires

Total Periodic Expenses

Client Action Plan

Client Name:

Client Number:

Client Address:


Client's Financial Concern:
Budgeting & Money Management
Credit Use
Mortgage Delinquency
Debt Management

Budget Assessment Summary

Total Gross Monthly Income:

Monthly Mortgage/Rent:

Minimum Monthly Living Expenses:

Total Monthly Expenses:

Net Income Monthly:

Debt Management Amount:

Potential Financial Resources:

Full Time Employment
Spouse's Employment
Additional Employment
Housing Options
Sell Automobile/Refinance
Tax Refund
Savings and Investments

Action Steps:


Advised to handle finances (on own)
Education Classes
Additional Income
Debt Management Program
Housing Assistance
Reduce Expenses
Referred - Attorney

Client Signature: