STATEMENT OF INITIAL 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.

• The agency will provide a confidential comprehensive personal money management interview. I am encouraged, but not obligated to use the advice, counsel and recommendations presented to me. This shall include budgetary advice given by the program and to otherwise perform such tasks as recommended.

• The interview will be conducted by a Certified Consumer Credit Counselor. All Credit Counselors have received their High School diploma or Bachelors Degree and are Certified Credit Counselors, as recognized by National Foundation for Credit Counseling. All instructors have one or more years experience in Financial Education or Credit Counseling.

• In the event you are dissatisfied, you may utilize the Complaint Resolution Process. A copy of this form is available upon request.

• Most of our funding comes from voluntary contribution from creditors who participate in Debt Management Plans (“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 your 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 of your creditors regardless of whether they contribute to our agency.

• The agency will provide counseling to all segments of the community regardless of ability to pay our fee. Services may be provided at a reduced rate or free, based on the client’s ability to pay.

• If your credit report reflects that I have paid creditors as agreed in the past, a DMP could have a negative impact on a creditworthiness decision by a potential creditor, landlord or employer in the future. In addition, creditors may report that you are on a DMP and are not paying as originally agreed although they have accepted the reduced payment. This agency does not report to any credit reporting agency. Participation in a debt repayment program may change information that is already on your credit report. I am also aware that debts to creditors I repay through the plan may be able to be discharged through bankruptcy. Counselors cannot provide legal advice. You agree to inform the agency of the decision if I file bankruptcy.

• A current list of creditors who typically participate in debt management plans may be provided to our clients upon request. However, final determination of this participation will not be determined until after a proposal has been received and considered by the creditor.

• At some time in the future, your information may be used for confidential research and/or a neutral third party may contact you to request an evaluation of the agency’s services. If your information is used, your anonymity will be maintained through the use of your client number or by using aggregate data.

• As a client of Chestnut Credit Counseling Services, you have a right to choose between our budget counseling and debt management services, or bankruptcy, or whatever recourse you choose to resolve your financial difficulties. If you believe that the time and effort involved in following a debt management plan would create an unreasonable hardship on you and your family, you may choose other options.
 You will be given a written assessment outlining a suggested client action plan which will be based on the following options:
 You will handle any financial concerns on your own.
 You may choose to enroll in the agency’s Debt Management Plan. Our DMP’s serve the dual role of helping you repay your debts and helping creditors to receive the money owed to them.
 You 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. You have a right to use or reject any referrals offered by CCCS staff.

I acknowledge the receipt of this form and I (we) am requesting to receive financial counseling with Chestnut Credit Counseling Services.