BANKRUPTCY COUNSELING AND EDUCATION DISCLOSURES
Family Service Association of Sheboygan, Inc./Consumer Credit Counseling Service (hereafter referred to as FSA) is a non-profit 501(c)(3) corporation. We are an approved Budget and Credit Counseling Agency * whose goals are to help you complete the required pre-filing counseling and pre-discharge education and provide you with the certificates you will need should you choose to file bankruptcy. All of our counselors are certified by the National Foundation for Credit Counseling.
*Approval by the Department of Justice does not endorse or assure the quality of the agency’s services.
Legal Advice: I understand that a counselor may answer questions about bankruptcy, but it is not legal advice. If I want legal advice, it is my responsibility to contact an attorney. While an attorney can make recommendations to file bankruptcy, it would be my personal choice.
Counseling Goals: The counselor is an NFCC certified Bankruptcy Counselor. The goal of a financial assessment is to provide me with a comprehensive overview of my financial situation, including a budget, list of debts, review of assets, a suggested plan of action and alternatives that I might have available to me. These alternatives may include a Debt Management Program that could be provided by FSA.
Bilingual Services: FSA will provide free bilingual instruction or professional interpreter assistance to any limited English proficient debtor.
Impact on your Credit Report and Credit Score: Your credit report or credit score will not be affected by budget, credit, or bankruptcy counseling or any educational program taken through FSA. FSA does not report to any credit reporting agency or credit bureau. However, I understand that my credit report and credit score could be negatively impacted if I file bankruptcy or select some other alternative to bankruptcy such as nonpayment of obligations or debt settlement.
Disclosure of Funding Sources: FSA is a non-profit 501(c)(3) corporation that receives funding from a variety of sources including but not limited to: local United Ways, donations and contributions from individuals, businesses and other organizations including service clubs and churches, local grants and contracts, creditor contributions, credit grants, and fees for services provided to individuals and groups. The agency does not pay or receive any fees or other consideration for the referral of debtor student or clients to or by Family Service Association of Sheboygan.
Complaint Resolution Process: I am aware of the Complaint Resolution Process as outlined on the back of this form.
Fees for Bankruptcy Counseling and Education. I have received and understand the fee schedule for services for Bankruptcy counseling and Bankruptcy education services. I understand that the appropriate certificates will be issued within the guidelines Executive Office of US Trustee.
Fee Waiver – FSA provides counseling and education programs regardless of an individual’s ability to pay. Services are available for
- The attorney is filing pro bono.
OR
- The majority of income is from disability AND the household income is equal to or less than 150 percent of the poverty guidelines last published by the United States Department of Health and Human Services (DHHS) applicable to a family of their size. The income of a spouse is included in calculating income whether or not a joint petition is filed, unless the spouses are separated and a joint petition is not filed.
In either case, documentation MUST be provided.
Fees and Issuance of Certificates: The following fees include any fees associated with the generation of the certificate.
Bankruptcy Counseling (pre-filing): $50 single/$65 joint
(Call us to be regsitered at 800-350-2227 - Cashier's check, money order, debit card accepted)
Bankruptcy Education (post filing, online – we register you) $50 single/$65 joint
Bankruptcy Education (post filing, online – self-register) $35 single/$50 joint
All fees shall be paid by cashier’s check, money order, debit card or cash prior to the issuance of any certificates. The agency has an obligation to provide a certificate to the debtor promptly upon the completion of counseling services/education services. A bankruptcy counseling client will only receive a certificate if the client completes counseling services. A debtor education client will only receive a certificate if the debtor completes an instructional course.
I understand that sometime in the future, my information may be used for confidential research and/or a neutral third party may contact me to request an evaluation of the agency’s services. I further understand that FSA may disclose my information to the US Trustee in connection with the Trustee’s oversight of FSA, the Provider, or during the investigation of complaints, during onsite visits, or during quality of service reviews.
The United States Trustee has neither reviewed nor approved any other services the agency provides to clients.
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.
I have read all of the above disclosures and statements and fully understand them. I understand this is not a contract.
CCCS of Sheboygan
1930 N. 8th Street
Sheboygan, WI 53081
920/458-3784
CCCS of West Bend
139 N. Main
Suite 101
Suite 101
West Bend, WI 53090
262/306-9241
CCCS of Fond du Lac
17 Forest Avenue
Suite 016
Suite 016
Fond du Lac, WI 54935
920/907-4344
CCCS of LaCrosse
505 King Street
Suite 212
LaCrosse, WI 54601
608/784-8380
Revised 8/5/19
POLICY ON CLIENT RIGHTS
As a client of Family Service Association, you have the following rights:
• To be treated with dignity and respect.
• To be actively involved in any plan developed for you.
• To withdraw from any service at any time.
• To have complaints addressed in a timely manner.
• To speak freely in an appropriate manner and to have your concerns addressed.
• To ask questions and be informed of your rights as a client of Family Service Association.
COMPLAINT RESOLUTION PROCESS
We are committed to providing you with high quality professional services. However, if you are not satisfied with the services provided or if you want to make a complaint, we ask that you follow these guidelines:
- First, try to resolve the issue with the staff member involved giving them specific information about your complaint. If this is not possible, or the issue is not resolved to your satisfaction, please write a letter or call the Executive Director of Family Service Association at 920/458-3784.
- We may request a meeting with you or seek more information from a staff person.
- We will respond within 15 days.
- Finally, if your issue is still unresolved, you may appeal directly by letter to the agency’s Board President. After additional fact finding, the Board President will provide a concluding decision to you within 15 days.
POLICY ON NON-DISCRIMINATION
Family Service Association shall not discriminate in the selection and participation of clients in its programs with respect to race, religion, color, gender, age, national origin or disability. No criteria other than those required by funding sources or by federal or state law(s) shall be used to determine client eligibility.
Clients who feel that they have been discriminated against in the provision of services by Family Service Association on grounds of race, religion, color, gender, age, national origin or disability have the right to appeal to the Executive Director. The Executive Director or Administrative Assistant will accept your written complaint and make an appointment with the Executive Director for you.
POLICY ON CLIENT CONFIDENTIALITY
Family Service Association is committed to assuring the confidentiality of individuals and/or families who have contact with this agency.
We realize that the concerns you bring to Family Service Association are highly personal in nature. We assure you that all information shared both orally and in writing will be managed within legal and ethical considerations. This means that information will not be released to anyone except under the following conditions:
All Clients
To assist us in our work with you, our staff will seek supervision/consultation with professional colleagues within the agency and where appropriate and necessary with other resources in the community.
For the purposes of evaluating our services, gathering valuable research information and designing future programs, Family Service Association may use case file information. Your anonymity will be maintained through the use of your client number or by using aggregate data.
Bankruptcy and Credit Counseling Clients – We will confirm with your creditor or attorney if asked: 1) verification of appointment, 2) date of counseling and 3) disposition, i.e. 1) budget prepared, 2) certificate issued, or 3) other pending action.
Debt Repayment Clients Only - We may disclose the following to your creditors: your address and home phone number if published, social security number, total debt information, net income, living expenses, a list of your creditors, personal information concerning your financial circumstances as needed, but not life-style or personal habits. Telephone numbers at work will not be given out. Place of employment will be verified only.
In all other situations, your information may be released to appropriate individuals or agencies only upon your written request or when served by subpoena.
Revised 12/10/07