Debt Management Plan. Enrollment Forms

Transcription

1 Debt Management Plan Enrllment Frms 1

2 Page # Item Descriptin Directins 3 Authrizatin t pull Credit Cmplete sectin 1 (and 2 if necessary), initial where marked under sectin 3, and Reprt sign at the bttm. A cpy f yur driver s license is required t pull a cpy f yur 4-5 Authrizatin t autmatically withdraw funds frm a bank accunt 6 DMP Appintment Summary 7 Page 1 f DMP Agreement 8 Page 2 f DMP Agreement 9 Page 3 f DMP Agreement (Disclsure Statements 10 Client Cmplaint Reslutin Prcess CCCS Client Rights (these were included with yur infrmatin packet) Outstanding Debt Page (Included with yur Cunseling Package frm yur first appintment Repayment Schedule (included with yur Cunseling Package frm yur first appintment) credit reprt If yu chse t have yur payment withdrawn frm yur bank accunt, cmplete the frm, as marked and attach either a vided check r phtcpy f a check fr verificatin f yur banking infrmatin. Fir yu t read and review. This explains hw a debt management plan wrks. T read. There are n signatures required n this page. T read. A date needs t be determined fr when yur first payment will be due. This date shuld be entered in paragraph 3, alng with the mnthly amunt due fr yur debt management plan. Read and initial lines 1 thrugh 9, stating that yu have read and understd each statement Explains what yu shuld d if a prblem arises with anyne yu are wrking with at Chestnut Credit Cunseling Services. It gives yu ur Chain f Cmmand within ur rganizatin, s yu knw whm t cntact, shuld yu ever have an unreslved issue. T read and review Fr yur review. Please make sure all creditrs yu anticipated t be included are included n this page. Fr yur review explains prbable times t pay ff debt. Need interest rates fr sme creditrs as interest rates fr thse creditrs are based n a percentage f the current interest rates. In additin, we will need cpies f current creditr statements, shwing the full accunt number fr all creditrs t be enrlled in the debt management plan. Yur enrllment fee f $35.00 is als required t start the prgram. 2

3 Merchant Credit Reprts A service f Merchants Credit Infrmatin Slutins, LLC P.O. Bx 2070, Phenix, AZ / Fax pcr@merchantsinf.cm Web Site: ORDER FORM FOR OFFICE USE ONLY R# MOP By Date Credit Prfessinals Recmmend That Everyne Shuld Mnitr Their Credit Reprts Frequently. Merchants Credit Reprt = MCR Credit Reprting Agencies = CRA s Experian = XPN TransUnin = TU Please check the bx next t the Reprt/Reprts yu wuld like t rder MCR (2 CRA s) Withut Scre $.00 - Chse 2 CRA s MCR with Scre* $.00-2 CRA s with 2 Scres $.00-2 CRA s with 1 Scre Standard MCR (1 CRA) $.00 Experian $.00 Experian with Scre $.00 TU $.00 TU with Scre Chse 2 CRA s Chse 1 CRA XPN TU XPN TU Chse which Scre(s) yu want (must match MCR) Chse which Scre(s) yu want (must match MCR) XPN TU XPN TU * CreditXpert Scre is nt an actual FICO Scre. AUTHORIZATION AND IDENTIFYING INFORMATION TO REQUEST A MERCHANTS CREDIT REPORT Name Last First Middle Initial Jr., Sr., II, III, IV Scial Security Number Date Of Birth Current Address Huse Number N/E/W/S Street City State Zip Cde Previus Address Huse Number N/E/W/S Street City State Zip Cde Address Daytime Telephne # Under the Fair Credit Reprting Act (FCRA) any persn wh knwingly and willfully btains credit infrmatin frm a cnsumer reprting agency under false pretenses r vilates any f the prvisins f the FCRA may be liable fr a civil penalty f nt mre than $2,500 per vilatin. The persn, fr whm a Merchants Credit Reprt will be requested, must sign this frm. I certify that I am the persn named abve and that I am submitting this authrizatin t receive my cnsumer credit reprt fr my persnal review. Cnsumer s Signature Date Gvernment Issued ID and Expiratin Date 3 MAY14

4 Merchant Credit Reprts A service f Merchants Credit Infrmatin Slutins, LLC P.O. Bx 2070, Phenix, AZ / Fax pcr@merchantsinf.cm Web Site: ORDER FORM FOR OFFICE USE ONLY R# MOP By Date Credit Prfessinals Recmmend That Everyne Shuld Mnitr Their Credit Reprts Frequently. Merchants Credit Reprt = MCR Credit Reprting Agencies = CRA s Experian = XPN TransUnin = TU Please check the bx next t the Reprt/Reprts yu wuld like t rder MCR (2 CRA s) Withut Scre $.00 - Chse 2 CRA s MCR with Scre* $.00-2 CRA s with 2 Scres $.00-2 CRA s with 1 Scre Standard MCR (1 CRA) $.00 Experian $.00 Experian with Scre $.00 TU $.00 TU with Scre Chse 2 CRA s Chse 1 CRA XPN TU XPN TU Chse which Scre(s) yu want (must match MCR) Chse which Scre(s) yu want (must match MCR) XPN TU XPN TU * CreditXpert Scre is nt an actual FICO Scre. AUTHORIZATION AND IDENTIFYING INFORMATION TO REQUEST A MERCHANTS CREDIT REPORT Name Last First Middle Initial Jr., Sr., II, III, IV Scial Security Number Date Of Birth Current Address Huse Number N/E/W/S Street City State Zip Cde Previus Address Huse Number N/E/W/S Street City State Zip Cde Address Daytime Telephne # Under the Fair Credit Reprting Act (FCRA) any persn wh knwingly and willfully btains credit infrmatin frm a cnsumer reprting agency under false pretenses r vilates any f the prvisins f the FCRA may be liable fr a civil penalty f nt mre than $2,500 per vilatin. The persn, fr whm a Merchants Credit Reprt will be requested, must sign this frm. I certify that I am the persn named abve and that I am submitting this authrizatin t receive my cnsumer credit reprt fr my persnal review. Cnsumer s Signature Date Gvernment Issued ID and Expiratin Date 4 MAY14

5 AUTHORIZATION FOR ELECTRONIC ENTRIES TO BANK ACCOUNT The undersigned hereby authrizes Chestnut Credit Cunseling Services-CCCS (the Cmpany) t make electrnic debit entries and any necessary adjustments invlving these entries in the accunt identified belw at Cmmerce Bank, Blmingtn, IL (the Bank) and authrizes the Bank t accept such entries and make any necessary adjustments. It is agreed that these entries will be made under the Rules f the Natinal Autmated Clearing Huse Assciatin. This authrizatin will remain in effect until written ntice f terminatin is delivered t the Cmpany in a timely manner s as t affrd the Cmpany an pprtunity t act theren. In n event shall such terminatin be effective as t entries prcessed prir t receipt f such ntice. Accunt Infrmatin: Bank Name Accunt Type checking Savings Spend Accunt City & State Transit Ruting Number Accunt Number Name n Accunt Address (Please prvide yur address if yu wuld like t receive updates when changes are made) Signature f Authrizing Party: Date: Please attach a vided check r a phtcpy f a canceled check belw: CCCS nly: Client Number: Ttal Depsit Due: $ Withdrawal date: Disbursement date: Amunt per Withdrawal: $ Client Scheduled Start Date: Available dates t withdraw (YOU MAY CHOOSE ONE OF THE FOLLOWING OR A COMBINATION OF THE FOLLOWING: 5th 10th 15th 20th 26th Last calendar day f the mnth Bi-Weekly Every ther Friday (divide ttal depsit by 2). There will be twice per year when an extra payment will be withdrawn) Weekly Every Friday (divide ttal depsit by 4).There will be twice per year when an extra payment will be withdrawn. 5

6 ACH POLICY ACH (Autmated Clearing Huse) is the prcess in which mney is debited frm yur checking r savings accunt electrnically. This frm f payment is intended t be used as a permanent frm f payment. If yu plan t send in extra mney peridically, this may be accmplished by sending certified funds (in the frm f cash, cashier s check r mney rder) Changes must be received by CCCS n later than 5 business days befre change is t ccur. Specific changes must be listed Client name and CCCS client number Date f change Bank infrmatin including yur accunt number and bank ruting number Reasn fr change Amunt f the withdrawal Changes must be submitted in writing, either by letter, fax, r t CCCS. A respnse t yur request will be sent t yu upn receipt f yur request Changes are subject t discretin f CCCS staff. Only permanent changes will be allwed. Fr example, an increase r decrease in payments. Effective Octber 1, 2012, we will n lnger allw fr temprary freezes. If yu nly want yur payments t cme ut a certain number f times per mnth, yu may chse any cmbinatin f the available withdrawal dates listed belw. Shuld yur ACH be yur accunt will be charged a $29 fee. Any ACH withdraw that is returned a secnd time will als be charged a $29 fee and the ACH will be permanently stpped. All future depsits must be made by cashier s check, mney rder, r cash. Available dates t withdraw (YOU MAY CHOOSE ONE OF THE FOLLOWING OR A COMBINATION OF THE FOLLOWING: 5th 10th 15th 20th 26th Last calendar day f the mnth Bi-Weekly Every ther Friday (divide ttal depsit by 2). There will be twice per year when an extra payment will be withdrawn) Weekly Every Friday (divide ttal depsit by 4).There will be twice per year when an extra payment will be withdrawn. Changes must be received by CCCS n later than 5 business days befre the change is t ccur. Specific changes must be listed. Please include the fllwing infrmatin with yur change request: Client name and CCCS accunt number Effective date f change Bank infrmatin, including ruting and accunt number Reasn fr change Amunt f withdrawal Changes must be submitted in writing; either by letter, fax, r t CCCS Shuld yur ACH be returned, yur accunt wuld be charged a $29.00 fee. Any ACH withdrawal that is returned a secnd time will be charged a $29.00 fee and the ACH will be permanently stpped. A cashier s check, mney rder, r cash will be required n all future depsits. 6

7 DMP Appintment Summary Abut the Debt Management Plan: Debt Management Plans thrugh CCCS are t be used fr unsecured debts nly. Mst f the agency funding cmes frm creditrs participating in Debt Management Plans. Since creditrs have a financial interest in getting paid, mst are willing t make a cntributin f up t 15% t help fund the agency. Hwever, yur accunts will always be credited 100% f the amunt yu pay thrugh us, and we will wrk with all yur creditrs regardless f whether r nt they cntribute t ur agency. Many creditrs reduce the APR and stp late/ver-limit fees. Hwever, these cncessins may be granted nly after the prpsal has been accepted and 3 cnsecutive payments have been received. N new credit Yu may be drpped frm the DMP if yu cntinue t use my ld credit cards r undertake new credit respnsibilities. Creditrs may als determine acceptance f DMP based n recent credit use, age f the accunt, and whether r nt yu have enrlled previusly in a DMP. DMP participatin is reflected n yur credit reprt. $35 mnthly fee - $35 enrllment fee (individual), $35 (jint) One mnthly payment CCCS disburses fr each client nce per mnth n the 10 th r 25 th. Apprximately 5 years t pay ff accunt balances, depending n yur creditrs, mnthly payments, and interest rates assigned. My Respnsibilities: Check ver credit card statements fr fees, amunts past due and interest rates. If I see any f these peculiarities, I will first cntact my creditr and then CCCS if needed. I understand that I will receive my statements and nt CCCS. Send in payment by due date each mnth. I understand if my payment is late, incmplete r nnexistent, my creditrs may charge late fees r terminate my DMP. Cntact CCCS if I receive paperwrk frm the creditrs that is crucial t the DMP such as creditr change, accunt number change, accepted prpsals, etc. Send in cpies f statements every three mnths s CCCS can update my balances. Because the CCCS system des nt calculate finance charges, I need t peridically update balances with CCCS. The crrect balance is reflected n my statements and nt n CCCS quarterly reprts. Pay mre than my minimum payment when pssible in rder t liquidate the debts mre quickly. Cntact CCCS if I mve and have a change f address r phne number. Cancel all credit prtectin plans. Pay the creditrs thrugh CCCS. I will nt d check by phne, payffs n wn, etc. Destry r return t the creditr all credit cards enrlled in the CCCS plan. Any accunts nt listed in the debt management plan will be clsed. I understand that this DMP will nly be successful if I want it t be. I must have my payments in full and n time t the CCCS ffice by my due date. I will cntact the creditr and /r credit cunselr in a timely manner if I see any cncerns. I understand that this is nt a quick fix, but a prgram that requires effrt and time n my behalf. 7

8 AGREEMENT I/We wish t have Chestnut Health Systems, Inc., Chestnut Credit Cunseling Services set up a Debt Management Prgram (DMP) fr me/us. The DMP is the changing f any f my/ur debts, bligatin, liabilities r credit transactins with the peratin f the creditr. It includes, but is nt limited t adjustment, cmprmise, extensin, liquidatin, mdificatin, payment prrating, rearrangement, satisfactin, and settlement. I/We understand that all funds depsited t and held in trust by CCCS are my/ur prperty and are t be paid t thse creditrs indicated by me t CCCS. After enrllment in the DMP, I/we will prvide CCCS with a list f all my mnthly creditrs and the amunt wed t each creditr r with a cpy f each f my mnthly creditr statements. Once depsited in the CCCS Trust Accunt, and paid t thse creditrs, the funds will nt be returned t me/us. If I/we fail t make a full mnthly payment t CCCS, I/we may be dismissed frm the prgram and CCCS will ntify my/ur creditrs. I/We may at any time discntinue participatin in the DMP by ntifying CCCS in writing f my/ur wish t d s. I/We understand that CCCS will ntify my/ur creditrs f my/ur changes f plans. Creditrs may discntinue any cncessin granted during ur participatin n the DMP. I/We recgnize that in rder fr CCCS t establish and maintain my/ur DMP it will be necessary fr CCCS t furnish certain infrmatin cncerning my/ur financial cnditin t creditrs and thers wh have a need t knw. Therefre, I/we expressly authrize CCCS t: (1) disclse any infrmatin cncerning my/ur financial cnditin and status, including but nt limited t my/ur incme, debts, credit, earnings, and/r lcatin infrmatin t any creditr n the DMP, and t (2) btain whatever financial infrmatin cncerning me/us frm any f my/ur creditrs, as CCCS deems necessary. This permissin expires upn my discntinuatin f services with CCCS r at any time prir t discntinuatin with written ntice t CCCS. I/We recgnize that CCCS has n respnsibility r bligatin fr any past, present r future credit rating assigned t me/us by any f my/ur creditrs. Furthermre, I/we understand that CCCS is nt respnsible fr interest, late charges, penalties r ther miscellaneus charge by my/ur creditrs. I/We give CCCS permissin t btain balances and infrmatin regarding my/ur accunt(s) as needed fr my/ur Debt Management Plan. I/We affirm that nne f ur accunts cvered under the DMP will be used by anyne while participating in this prgram. I/We als affirm that all credit cards listed in the DMP have been destryed r returned t the issuing creditr. I/We understand that a prgram enrllment fee f $35.00 is required t start the prgram. I/We understand that a mnthly client fee f $35.00 will be charged t my/ur accunt t help pay fr the checks, pstage, and statinary t set and maintain my/ur prgram. 8

9 I/We understand that CCCS will disburse payments directly t ur creditrs. Payment due dates are the 5 th and 20 th. I/We will select ne date and have my/ur mnthly payment in the Blmingtn ffice by that date. I/We are permitted t pay by mney rder, cashier s check, r ACH. My/ur regular mnthly payment f $ (which includes the client fee) will begin n and cntinue n a regular basis thereafter. I/We hereby acknwledge that I/we have received, read, understand, and agree t abide by the infrmatin given in the fllwing dcuments: (Please initial n the line prvided fr each dcument.) DMP Appintment Summary Client Rights Client Cmplaint Reslutin Prcess / Nn-Discriminatin Plicy I understand that if I have any questins regarding my rights f the afrementined dcuments, I can cntact: David Hill CCCS Prgram Manager, Chestnut Credit Cunseling Services 1003 Martin Luther King Dr. Blmingtn, IL (309) Signed Address Date Client Signed Address Date Client Signed Chestnut Credit Cunseling Services Date 9

10 As an applicant fr a Debt Management Plan (DMP), I understand the fllwing: Please initial befre lines stating yu have read and understd the fllwing statements 1. Mst f ur funding cmes frm vluntary cntributin frm creditrs wh participate in Debt Management Plans ( DMP ). Since creditrs have a financial interest in getting paid, mst are willing t make a cntributin t help fund ur agency. These cntributins are usually calculated as a percentage f payments yu make thrugh yur DMP up t fifteen percent (15%) f each payment received. Hwever, yur accunts with yur creditrs will always be credited with ne hundred percent (100%) f the amunt yu pay thrugh us and we will wrk with all f yur creditrs regardless f whether they cntribute t ur agency. 2. The DMP serves the dual rle f helping yu repay yur debts as well as helping creditrs cllect the mney yu we them. 3. The length f my DMP will depend n my creditrs, the mnthly payments, and the interest rates assigned. An average time t expect in the prgram is abut 60 mnths. 4. I understand that all charges and fees made t my accunts by my creditrs are my respnsibility. 5. This agency des nt reprt t any credit reprting agency. Reprts, if any, are made directly by the creditr. In sme cases, a DMP may have a negative effect n yur credit bureau reprt. 6. Once I enter a DMP, all payments t creditrs listed n the prgram will be made thrugh Chestnut Credit Cunseling Services. This includes regular mnthly payments, extra payments and early payffs. I will make n payments directly t the creditrs while I am in the prgram. 7. Payments t my DMP are made mnthly. Due dates are the 5 th and 20 th. I will select ne date and have my mnthly payment in the Blmingtn ffice by that date. I am permitted t pay by cash, mney rder, cashier s check r ACH. If my bank returns my ACH, I understand there is a $29 returned ACH fee. Als if the bank returns my ACH, I will make all future payments in the frm f secured funds nly (mney rder r bank check). 8. All creditr statements are my respnsibility. While I am enrlled in the DMP, all creditr statements will cntinue t cme t me. I am respnsible fr ntifying creditrs f any change f address and verifying that all payments have been prperly credited t my accunts. CCCS will nt verify with my creditrs the accuracy f my statements r my statement balances. I will keep cpies f my statements fr my recrds. If I have a questin cncerning interest charges, late fees, ver limit fees, I will call the creditr. I may als send a highlighted cpy f the statement, keeping the riginal fr myself, t my cunselr fr clarificatin. If my cunselr infrms me that there is a payment discrepancy in my statement, I am respnsible fr reslving the discrepancy with my creditr. 9. Every mnth, I will receive a status reprt frm the Blmingtn ffice. The reprt will itemize the ttal amunt f funds I paid t CCCS during the previus mnth indicated n the reprt, alng with the ttal amunt paid frm my Trust Accunt t each f my creditrs, the amunt f charges deducted frm my Trust Accunt, including client fees, and any amunt held in reserve by CCCS. I may als request an itemized summary f my Trust Accunt activity by sending a request in writing t my cunselr at CCCS. CCCS will send the summary t me within 7 days f receipt f my request. If balances need t be updated, I will prmptly send cpies f my statements int the ffice. Client Signature Date Client Signature Date Cunselr Signature Date 10

11 CLIENT COMPLAINT RESOLUTION PROCESS We are cmmitted t prviding yu with high quality prfessinal services. Hwever, if yu are nt satisfied with the services prvided r if yu wuld like t make a cmplaint, please cnsider these guidelines: 1. Try t reslve the issue with the staff member. Please give the staff member specific infrmatin abut yur cmplaint. A cunselr respnse can be expected within 15 days. 2. If the issue is nt reslved t yur satisfactin, write t: Cheryl D. Fster, Certified Credit Cunselr, Chestnut Credit Cunseling Services, 370 Hublt Rad, Suite 101; Jliet, IL (Phne cntact: (800) A jint meeting with yu, Ms. Fster, and the staff member may be required t reslve the issue. An agency respnse can be expected within 15 days. 4. If yur issue remains unreslved, yu may call r write t David Hill, Credit Cunseling Crdinatr, Certified Credit Cunselr, Chestnut Credit Cunseling Services; 1003 Martin Luther King Drive; Blmingtn, IL, (Phne cntact: r ). A written respnse can be expected within 15 days. This respnse will be maintained in the client file, as applicable. 5. If yur issue still remains unreslved, yu may appeal t Mike Takamri, Directr f Business and Finance, Chestnut Glbal Partners; Chestnut Health Systems; 1003 Martin Luther King Drive; Blmingtn, IL, (Phne cntact: ). Mr. Takamri will prvide a cncluding decisin t yu within 15 days. This agreement is gverned and interpreted in accrdance with the laws f the State f Illinis and the Debt Management Services Act. Shall any disputes arise; either party may cntact the Illinis Divisin f Financial Institutins at (888) NON-DISCRIMINATION POLICY Chestnut Credit Cunseling Services serve all members f the cmmunity. We d nt engage in the practice f discriminatin in the selectin and participatin f clients in ur prgram with respect t race, religin, clr, gender, natinal rigin, r disability. 11