United Way Cummunity Partner

416 College Street, Beloit, WI 53511

Phone: 608-365-1244
Toll Free: 866-925-CCCS
FAX: 608-365-4097

Service Agreement

Please read the following statements carefully to understand CCCS procedures. Initial next to each statement to indicate understanding for that provision. For simplification the singular is used even when the plural may apply.

Please print fill out and bring to first appointment.

I understand the program 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 Consumer Credit Counselor. All action plans not conducted by a Certified Consumer Credit Counselor will be reviewed by a Certified Credit Counselor.

I understand if I am dissatisfied, I can utilize the Complaint Resolution Process, outlined below.

I understand that most funding comes from voluntary contributions 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 the agency. These contributions are usually calculated as a percentage of payments made through the DMP, which can be up to fifteen percent (15%) of each payment received. However, all accounts with creditors will always be credited with one hundred percent (100%) of the amount paid through CCCS. CCCS will work with all creditors regardless of whether they contribute to the agency.

I understand that DMPs serve a dual role of helping individual s and families repay debt and helping creditors collect the money owed them.

I further agree to hold CCCS, its employees, officers, directors, and agents harmless from any claim, suit, action, or demand of my creditors, myself, or any other person arising out of this agreement or resulting from advice or counseling. Any forms, agreements, contracts or other materials provided to a client will not limit the client's right to seek damages against a non-profit budget and credit counseling agency as provided for in 11 U.S.C. 111 (g)( 2 ).

I understand that I will be given a written assessment based on the following options:

a) I may be advised to handle financial concerns on my own. b) I may choose to enroll in the program's Debt Management Plan. Under the DMP the agency serves as a neutral third party in negotiating with creditors to liquidate financial obligations.

Your participation in a Debt Management Program will not change anything which is already on your credit report. If your credit report reflects that you have paid creditors as agreed in the past, a Debt Management Plan 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 Debt Management Plan and are not paying as originally agreed although they have accepted the reduced payment.

c) A counselor may answer questions about bankruptcy, but not give legal advice. You should also be aware the debts to creditors you repay through the plan may be able to be discharged through bankruptcy.

d) I may be referred to other services of the organization or another agency or agencies as appropriate that may be able to assist with the problems that have been identified.

At 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.


Print Name


Print Name

Counselor's signature Date

I authorize the employees of Consumer Credit Counseling Service to discuss any and all aspects of my financial affairs with whom they deem necessary and obtain a consumer credit report in order to help me solve my financial problems.

Complaint Resolution Procedure

Step One Try to resolve the issue with the staff member involved by giving them specific information of the complaint and setting forth a reasonable time frame for resolution.

Step Two Contact the Program Manager in writing, describing the conflict or circumstances involving your complaint. You will then be contacted by the Program Manager for a consultation.

Write to: Program Manager- CCCS
205 N. Main Street, Suite 107
Janesville, Wisconsin 53545
608-752-5813 608-365-4097 (fax)

Step Three If a resolution is not forthcoming, you may contact the Wisconsin Department of Financial Institutions, the State agency which regulates the credit counseling industry.

Dept. of Financial Institutions
P.O. Box 7876
Madison, Wisconsin 53707-7876