CONSUMER CREDIT COUNSELING MAILING ADDRESS 185 RIDGEDALE AVE

Dear Client, Welcome to CCCS of New Jersey. Before your counseling appointment, please sign, complete and return the enclosed forms to us. 1.) Bankruptcy Counseling Waiver and Release (please initial and sign) 2.) Assets Worksheet (please complete and sign) 3.) CCCS of New Jersey Disclosure (please sign) 4.) Pre-filing Bankruptcy Privacy notice (please sign) 5.) General Information Worksheet (complete BOTH sides) (DO NOT SEND CREDIT REPORT) 6.) Please provide a copy of a recent paycheck stub or income verification. FOR HOMEOWNERS ONLY: 7) Privacy Principles (keep for your records) 8) Privacy Agreement (please sign) The fee for the counseling session and certificate is $50 PER PERSON. 3 WAYS TO RETURN YOUR COMPLETED FORMS WITH FEE: 1. Fax forms with a voided check (to debit your account) to 973-267-0484. 2. Mail forms with money order to address below. 3. Drop off forms with money order or cash at the address below. Our business office: CCCS OF NEW JERSEY 185 Ridgedale Ave. Cedar Knolls, NJ 07927-1812 These forms and income verification MUST be completed, signed, and returned to us before we can schedule your counseling appointment in order to obtain your Certificate of Credit Counseling. If the forms are incomplete, we cannot proceed with the counseling session and you will not obtain your certificate. Once we receive your forms, we will call you to schedule a phone counseling appointment. Please call us with any questions. We look forward to working with you. Sincerely, Consumer Credit Counseling Service of New Jersey Please keep in mind that we also provide debtor education, which is also required by the U.S. Trustee before your bankruptcy can be finalized. We offer this course online. You can get more information by clicking on the Money In Motion icon on our website at www.cccsnj.org. Register by calling our business office at 888-726-3260. Consumer Credit Counseling Service of New Jersey Bankruptcy Counseling Waiver and Release Please initial the following releases (#1-3) after reviewing the statements. If married and spouse is also filing, BOTH must initial. You MUST initial Release #1. However, you MAY initial Release #2 and #3 if you authorize CCCS to disclose your information to your attorney and/or you request CCCS send your Credit Counseling Certificate directly to your attorney. Please provide the attorney’s name and address if you agree to Release #2 and #3. 1. ____ _____ Client understands that CCCS’ budget analysis of Client’s income/expenses may differ from a bankruptcy attorney’s budget analysis. 2. ____ _____ Client consents to any employee of CCCS sharing information regarding client’s counseling session with Client’s attorney or law firm staff. 3. ____ _____ Client requests that ORIGINAL Credit Counseling Certificate and Debt Management Plan (if offered by CCCS Counselor) will be MAILED/FAXED (please circle option desired) directly to Client’s attorney/law firm. My/our attorney: name___________________________________________________________________ address_________________________________________________________________ fax______________________________ The client(s) hereby agrees to hold CCCS, its employees, officers, directors and agents harmless from any claim, suit, action, or demand made by any creditors or attorneys in connection with any services rendered by CCCS to the client(s). Nothing herein shall apply to actions or claims under the provisions of the United States Bankruptcy Code, 11 U.S.C. sec. 101 et seq. CCCS agrees that all information in the client(s) file will be otherwise kept confidential and used only for legitimate business purposes under the Fair Credit Reporting Act _______________________________ Client Signature _______________________________ Client Signature _____________________ Date _____________________ Date Assets Worksheet Cash and Cash Equivalents Checking account #1 Checking account #2 Savings account #1 Savings account #2 Certificates of Deposit Other Investments (non-retirement) Mutual Funds (total) Stocks (total) Bonds (total) Retirement Funds IRAs (total) 401(k) (total) 403(b) (total) SEP/SIMPLE (total) Company Retirement Plans (vested) Real/Personal Property Home (current market value) Land Auto #1 (current market value) Auto #2 (current market value) RV/Plane/ATV RV/Plane/ATV Other Personal Property Household Goods Furniture Jewelry Computers Home Entertainment Centers Tools Valuable Collections Total Assets Client: _______________________________ Client: _______________________________ Value Date:__________ Date:__________ CCCS of New Jersey Disclosure for Pre-Filing Bankruptcy Counseling Welcome! We understand that you are seeking counseling because you are experiencing financial problems, and that you may be considering filing for bankruptcy and are required to receive “counseling” before you may file. This agency has over 27 years of experience of helping people with financial problems. Our role is not to be judgmental, but to provide assistance. 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 your 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 consider alternatives to bankruptcy to resolve your problems. It is our view that the purpose of this session is to provide you with information so that YOU may chose the option that you think is best. At the conclusion of this session, you will be provided with a certificate that you will need should you decide to file for bankruptcy. The certificate is valid for up to 180 days after the counseling session. This agency is a member of the National Foundation for Credit Counseling (“NFCC”). The NFCC has high standards for quality credit counseling and financial education, and this agency complies with those standards. In addition, this agency is accredited by the Council on Accreditation, an independent third-party organization that reviews and monitors entities that provide social services. We are a non-profit agency, organized in accordance with Section 501(c)(3) of the IRS Code. The consumer credit counselor conducting or supervising this session has been trained and certified in accordance with the NFCC standards, and while he/she has expertise in helping those with financial problems, he/she 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. This agency also receives funding in the form of grants from Housing and Urban Development (HUD), Citibank, The IOLTA Fund of the Bar of New Jersey and many others. A significant portion of funding for this agency comes from voluntary contributions from creditors who participate in debt repayment programs. Since creditors have a financial interest in having debts repaid, many are willing to make a contribution to help fund the overall services of this agency. These contributions are usually calculated as a percentage of payments that are made through a debt repayment program. CCCS does not pay or receive fees for the referral of its clients to or by this CCCS. In order to assist you, it is essential that you provide us with information that is as accurate and complete as possible. For that reason, we may ask you to authorize us to access your credit history. Rest assured that the information concerning your financial condition and status that you provide during this session is strictly confidential. Such information would include, but is 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. This agency will not disclose or provide any information about this session to a credit-reporting agency. Should you decide to enter into a debt repayment program (which will be explained in the course of this session) you will be provided with separate agreement and disclosure forms. Know that enrolling in the debt repayment program administered by CCCS may damage a your credit rating for up to 7 years and bankruptcy will stay on your credit report for 10 years. To help cover the cost of providing this session to you, this agency charges a fee of $50 per individual (checks or money orders will be accepted.) Fees are waived if you are filing through your county legal services or your income is at or below 2008 Federal Poverty Level guidelines. In any case, services will not be withheld due to a client’s inability to pay. I have read and understand the disclosures made above. Signature: ______________________________ Printed Name: _________________________Date: ____________ Signature: ______________________________ Printed Name: _________________________ Date: ___________ CONSUMER CREDIT COUNSELING SERVICE OF NEW JERSEY, INC. PRE-FILING BANKRUPTCY PRIVACY NOTICE 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 your attorney or law firm 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. 2. 3. 4. We do not disclose any nonpublic personal information about our clients or former clients to anyone, except as permitted by law. 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. We may disclose some or all of the information that we collect, as described below, to attorneys or law firms that you have authorized who need this information in order for us to assist you after a counseling session. 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 information. 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. We may disclose, if applicable, 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. 5. 6. RELEASE: I hereby authorize this Credit Counseling Agency to release all non-public information it obtains about me to my attorney or law firm staff to resolve the matter(s) discussed during my counseling session. I further RELEASE and authorize my attorney or law firm to provide non-public information about me to this Credit Counseling Agency. Client__________________________ ___________________________ Date_____________ Client__________________________ ___________________________ Date_____________ CONSUMER CREDIT COUNSELING SERVICE OF NEW JERSEY, INC. MAILING ADDRESS: 185 RIDGEDALE AVE. CEDAR KNOLLS, NJ 07927-1812 TELEPHONE: (973) 267-4324 FAX: (973) 267-0484 (888) 726-3260 IN-PERSON COUNSELING COUNSELING BY PHONE DAY NIGHT PLEASE CHECK YOUR CHOICE: LAST NAME (PLEASE PRINT) ADDRESS CITY CLIENT 1 CLIENT 2 OTHER INCOME EXPENSES HOUSING Rent or Mortgage Oil Gas Electricity Telephone FOOD Groceries Lunches (Work & School) TRANSPORTATION Car Payments Gasoline/Oil Insurance INSURANCE Life (Whole/Term) MEDICAL Insurance (hospital/Medical) Doctor//Therapist/Optometrist Dentist Prescriptions/Medications CLOTHING FOR ENTIRE FAMILY EDUCATION (TUITION) PERSONAL Alimony & Child Support Baby Sitter/Day Care Entertainment Gifts (Birthdays, Holidays) $ $ SOURCE OF OTHER INCOME WEEKLY STATE TAKE HOME PAY ZIP WEEKLY FIRST NAME CLIENT 2 NUMBER IN HOUSEHOLD HOME PHONE #: WORK PHONE# MONTHLY BI-WEEKLY CLIENT 1 SINGLE MARRIED SEMI-MONTHLY MONTHLY YEARLY WEEKLY MONTHLY Pet Care Other CREDITOR INFORMATION CLIENT COMPLETE CLEAR SECTIONS CUR CREDITOR, COLLECTION AGENCY LAWYER, ACCOUNT BALANCE APR NUMBER SHADED SECTIONS FOR OFFICE USE ONLY: % TOT ADJ WTD % DMP DEBT APR AVG MIN PYMNT ACCT #: ACCT #: ACCT #: ACCT #: ACCT #: ACCT #: ACCT #: ACCT #: ACCT #: ACCT # ACCT #: ACCT #: ACCT #: THIS SECTION FOR OFFICE USE ONLY: MONTHS OF PROGRAM = TOTAL DEBT MONTHS TO REPAY PRINCIPLE @ WEIGHTED AVERAGE = ESTIMATED LENGTH MONTHLY DEPOSITS FOR HOMEOWNERS ONLY: NATIONAL FORECLOSURE MITIGATION COUNSELING PROGRAM Privacy Principles INTRODUCTION Consumer Credit Counseling Service of New Jersey, Inc. (“the Agency”) is an IRC 501(c)(3) nonprofit financial and credit counseling agency. Through its membership in the National Foundation for Credit Counseling (“NFCC”), the Agency is participating in the National Foreclosure Mitigation Counseling Program (“NFMCP”). The NFMCP is a federal program created and funded by Congress and administered by NeighborWorks America (“NWA”). By participating in the NFMCP, the Agency is able to provide you with assistance and counseling in dealing with your mortgage concerns. However, in order to provide you with the NFMCP assistance and counseling, it is necessary to collect nonpublic personal information about you and your financial situation, and to submit that information to the NFCC and NWA for purposes of administering the program. The Agency is committed to assuring the privacy of individuals and/or families who have contacted us for assistance. We realize that the concerns you bring to us are highly personal in nature. We assure you that all information shared both orally and in writing will be managed within the legal and ethical considerations and requirements of the NFMCP and in accordance with the policies described herein. If you have any questions about these policies, or our privacy practices, please contact us at 973 267-4324. TYPES OF INFORMATION WE GATHER ABOUT YOU. We may collect the following types of nonpublic personal information from you (hereinafter referred to as “Personal Information”): • • • • • Information that we receive from you orally or in writing, or 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 balances, payment history, parties to transactions and credit usage; Account information, including account balances, payment history, and account usage; Information that we obtain from non-affiliated third parties about your transactions with them; and Information we receive from a credit reporting agency, such as your credit history. CATEGORIES OF PERSONAL INFORMATION THAT WE DISCLOSE AND THE CATEGORIES OF NON-AFFILIATED THIRD PARTIES WITH WHOM WE SHARE THE INFORMATION • As part of the NFMCP, we will disclose some or all of the Personal Information to the NFCC, NeighborWorks America (“NWA”), and their administrators, subsidiaries, program monitors, and agents. These disclosures are a requirement of our participation in the NFMCP, which makes our services possible. We may disclose some or all of the Personal Information to your creditors or other non-affiliated third parties, such as financial service providers or creditors, where we have determined (i) that it would be helpful to you, (ii) that it would aid us in providing our counseling services to you, (iii) in order to fulfill a service requested by you, (iv) or where it is a requirement of participation in the NFMCP. All nonaffiliated companies that act on our behalf and receive Personal Information from us are contractually • obligated to keep the information we provide to them confidential, and to use the Personal Information we share only to provide the services we ask them to perform. • • In order to provide our services to you, we also may share any of the categories of Personal Information within our organization, to subsidiaries, affiliates or other related entities. We may also disclose any Personal Information about you to anyone as permitted by law (e.g., if we are compelled by legal process) or in the good faith belief that such action is necessary in order to conform to the requirements of law or comply with legal process served on us, protect and defend our rights or property, including the rights and property of the Agency or act in urgent circumstances to protect the personal safety of consumers who use our services. We may also disclose any or all Personal Information to the following parties or in the following instances: (i) NFCC, NWA, or their administrators, subsidiaries, program monitors, and agents to the extent that it is a requirement of participation in the NFMCP, which make our services possible; (ii) nonaffiliated third parties, such as financial service providers or creditors; (iii) our organization, subsidiaries, affiliates or other related entities; (iv) or as permitted by law (e.g., if we are compelled by legal process). • In addition, the Agency reserves the right to disclose certain Personal Information that it does not currently disclose to the non-affiliated parties referenced above. From time to time, we may also use anonymous aggregated case file information for the purpose of evaluating our services, gathering valuable research information and designing future programs. This data is not personally identifiable. RIGHT TO OPT-OUT OF CERTAIN DISCLOSURES. • You have the right to opt-out or prevent us from making disclosures of your Personal Information to non-affiliated third parties such as your creditors or other parties we feel would be helpful to you or that would aid us in counseling you. If you choose to opt-out, we will not be able to answer questions from your creditors. To opt-out, please contact us at 973 267-4324. You have the right to opt–out or prevent us from making disclosures of your Personal Information to the NFCC, NWA, or their administrators, subsidiaries, program monitors, and agents; however opting-out will terminate the NFMCP counseling services provided to you because the Agency cannot provide these services to you without disclosing your Personal Information. To opt-out, contact us at 973 2674324. If at any time, you wish to change your decision with regard to your opt-out, you may contact us at 973 267-4324. • • THE CONFIDENTIALITY AND SECURITY OF YOUR INFORMATION. Within the Agency, we restrict access to 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. FOR HOMEOWNERS ONLY: NATIONAL FORECLOSURE MITIGATION COUNSELING PROGRAM Privacy Agreement Consumer Credit Counseling Service of New Jersey, Inc. (“the Agency”) is an IRC 501(c)(3) nonprofit financial and credit counseling agency. Through its membership in the National Foundation for Credit Counseling (“NFCC”), the Agency is participating in the National Foreclosure Mitigation Counseling Program (“NFMCP”). The NFMCP is a program created and funded by Congress and administered by NeighborWorks America (“NWA”). By participating in the NFMCP, the Agency is able to provide you with assistance and counseling in dealing with your mortgage concerns. However, in order to provide you with the NFMCP assistance and counseling, it is necessary to collect nonpublic personal information about you and your financial situation (“Personal Information”), and to submit that information to the NFCC and NWA for purposes of administering the program. Accordingly, we are required to ask your consent to the following: • I understand that the Agency receives funds appropriated by Congress for the National Foreclosure Mitigation Counseling Program (“NFMCP’) to NeighborWorks America (“NWA”) as part of the National Foundation for Credit Counseling (“NFCC”) Intermediary. I understand that through the NFMCP, the Agency provides mortgage and foreclosure mitigation counseling services. As part of the counseling services, I will receive a written action plan consisting of recommendations for handling my finances, possibly including referrals to other entities as may be appropriate. As a condition of participation in the NFMCP, I understand that the Agency is required to collect and share some or all of my Personal Information with the NFCC, NWA, their administrators, program monitors, and agents for purposes of program monitoring, compliance and evaluation of this federal program. I acknowledge that I have received a document entitled “Privacy Principles” which outlines the types of Personal Information that the Agency will collect and may share, and with whom that information may be shared. As part of the NFMCP, I authorize the Agency to collect my Personal Information, as defined in the Privacy Principles, and to disclose or share it with the National Foundation for Credit Counseling (“NFCC”), NeighborWorks America (“NWA”), or their administrators, subsidiaries, program monitors and agents. I understand that this consent to the disclosure or sharing of my Personal Information will remain in effect until it is revoked or modified by me, and that this revocation or modification may occur at anytime by contacting the Agency at 973-267-4324. I understand that the revocation or modification of my consent will result in the termination of the NFMCP mortgage and foreclosure mitigation counseling services provided to me because the Agency cannot provide NFMCP services without disclosing my Personal Information as outlined. I understand that other services offered by the Agency may be recommended, or that I may be referred to other entities, as appropriate, to assist with particular concerns that have been identified. I understand that I am not obligated to use any of the services offered to me. I understand that the Agency’s counselors may answer questions and provide information, but not give legal advice. If legal advice is required, I may be referred for appropriate assistance. Date______________________ Date______________________ • • • • • • • • Client signature____________________________ Client signature____________________________