Tabor Community Services : Financial & Homeownership Services : Consumer Credit Counseling of Central PA : Accessing Our Services : To schedule a credit counseling appointment:

Statement and Privacy Policy *REQUIRED*

I have read, accept and understand the above counseling services statement and privacy policy.

How did you find out about us? *REQUIRED*

If Other, please specify

YOUR PERSONAL INFORMATION

Last Name *REQUIRED*

First Name *REQUIRED*

Middle Initial

Birthdate *REQUIRED*

mm/dd/yyyy

Primary phone *REQUIRED*

Unlisted *REQUIRED*

Work Phone

Is it okay to call you here?

Email Address *REQUIRED*

Street Address *REQUIRED*

City, State, Zip Code *REQUIRED*

County *REQUIRED*

*Please complete if you are buying or own your home

Present value of property

Balance of 1st mortgage

Balance of 2nd mortgage

Balance of home equity loan

Are you behind in your mortgage payments? *REQUIRED*

Yes
No
Not applicable

How many months?

Do you have other real estate?

Value

Marital Status *REQUIRED*

# of children at home *REQUIRED*

Other residents

Partner's Full Name

First, Middle, Last

Spouse's Birthdate

mm/dd/yyyy

Your Employer *REQUIRED*

Company Name & Address (Street, City, State, Zip Code)

Partner's Employer

Company Name & Address (Street, City, State, Zip Code)

List year and make of vehicles owned or leased

List all recreational vehicles

* * *

Now we need to see what your monthly income and expenses look like.

WHAT YOU MAKE AND WHAT YOU SPEND

The next section will guide you through listing what you bring in and where your money goes each month. Be realistic when you fill in the numbers. If you can't be realistic, be conservative - underestimating your income and overestimating your expenses. Have all your bills, receipts, bank statements, etc. in front of you and have your spouse or partner help.

- Tell us how much you make each month (net income)

Full-time job *REQUIRED*

Part-time job *REQUIRED*

Government Benefits *REQUIRED*

Child or Spousal Support *REQUIRED*

Other Sources *REQUIRED*

Total Income *REQUIRED*

- Tell us what you spend

Rent or Mortgage *REQUIRED*

Property Taxes *REQUIRED*

Home Maintenance *REQUIRED*

Homeowners or Renters Insurance *REQUIRED*

Electricity *REQUIRED*

Gas/Oil/Propane *REQUIRED*

Water/Sewer/Trash *REQUIRED*

Telephone *REQUIRED*

Cable/Internet *REQUIRED*

Groceries & Supplies *REQUIRED*

Public Transportation *REQUIRED*

Work Lunches (meals, snacks) *REQUIRED*

School Lunches *REQUIRED*

Dining Out *REQUIRED*

Gasoline for Vehicle *REQUIRED*

Car Maintenance (Registration, Inspection, oil changes, etc) *REQUIRED*

Parking, Tolls, Garage Rent *REQUIRED*

Auto Insurance *REQUIRED*

Barber Shop / Hair Salon / Nails *REQUIRED*

Children's Allowance / School Expenses *REQUIRED*

Cosmetics & Toiletries *REQUIRED*

Baby Supplies *REQUIRED*

Cigarettes / Tobacco & Alcohol *REQUIRED*

Laundromat/Dry Clean *REQUIRED*

Clothing, including Work Uniforms *REQUIRED*

Out of Pocket Medical Expenses *REQUIRED*

Medical Insurance Premium *REQUIRED*

Gifts ( Holidays / Birthdays/ Anniversaries) *REQUIRED*

Donations *REQUIRED*

Video Rental / Movies *REQUIRED*

Hunting / Fishing / Sports / Gym / Memberships *REQUIRED*

Gambling (Bingo, Lottery, Casino) *REQUIRED*

Vacations / Trips / Parties / Entertaining *REQUIRED*

Crafts / Hobbies / Pets *REQUIRED*

Child Care *REQUIRED*

Alimony/Child Support *REQUIRED*

Total your expenses here *REQUIRED*

* * *

Finally, let's look at...

YOUR DEBTS

All your debts must be listed below before an appointment can be scheduled.

Please begin a new line for each listed debt *REQUIRED*

Remember to include car loans and leases, credit cards, lines of credit, consumer loans, medical bills, tax and utility arrears (past due amounts), student loans, and other debts you owe. The prefix is the first six digits of the credit card number.

__ Include: # Debt, Creditor Name, Prefix (1st 6 digits), Type of Debt, APR, Balance, Monthly Payment

If Other, please specify

* * *

COMPLETING THE INTAKE PROCESS

Once we have your information, we will contact you to set up your free appointment.

Please choose how you want us to contact you to set up the appointment *REQUIRED*

By email
By phone

If by phone...

...which phone?

Primary
Work
Other

...which times?

If Other Phone, please list the number & specify where we are calling

You must bring the following documents to your CCCS appointment:
• Proof of your income:
- Three Pay Stubs or
- Your bank statement if you have direct deposit or
- Statement of benefits if you are receiving unemployment
• Your Recent Household Bills
• Social Security Numbers for you and your partner
• Recent Account Statement from all your Creditors
• A Current Credit Report
• Available free from annualcreditreport.com
- or
• By mailing to: Annual Credit Report Request Service PO Box 105281 Atlanta GA 30348-5281

Remember:
• No children at the time of the appointment;
• Expect a 1 1/2-hour appointment.

Cancellation Policy- You must cancel 24 hrs before scheduled appointment; otherwise appointment is classified as a "no show". There will be a $20 fee to reschedule.

P.S. If you still have questions about the CCCS process or filling out this form, you may call 717-397-5182, extension 112. Leave your question on the answering service with your phone number and the best time for someone to return your call. Or you can email your questions to cccs@tabornet.org.

Consumer Credit Counseling Service of Central Pennsylvania (CCCS of Central PA)
A division of Tabor Community Services
308 East King Street
P.O. Box 1676
Lancaster, PA 17608-1676
(717) 397-5182
fax (717) 399-4127
(800) 788-5062 (in Pennsylvania only)

When you click "Send Now", you will be brought to a confirmation page and receive a confirmation email letting you know that this application has been submitted successfully.

To schedule a credit counseling appointment:

Call us at: 800-788-5062 (toll free) or 717-397-5182

Choose one of two ways to request a Credit Counseling Appointment electronically:

YOUR PERSONAL INFORMATION

WHAT YOU MAKE AND WHAT YOU SPEND

- Tell us how much you make each month (net income)

- Tell us what you spend

YOUR DEBTS

COMPLETING THE INTAKE PROCESS