Consumer Credit Counseling Services (CCCS)
316 Green Street   Fayetteville, NC  28302   (910) 323-3192

Online Counseling Application

* denotes required fields.
Contact Information
* First Name

* Last Name


* Birth Date
Co-applicant First Name

Co-applicant Last Name


Birth Date
* Home Phone

Cell Phone
* Email Address

* Verify Email Address
* Street Address

City                                 State       Zip
* How long have you lived at your current address?

  years              months
Previous Street Address

City                                 State     Zip
How long did you reside at your previous address?

  years              months

*Highest Grade Completed

High School  Community Technical School  College  Graduate 


American Indian or Alaska Native  Asian  Black or African American
Hispanic or Latino  Native Hawaiian or Other Pacific Islander  White

* Marital Status

Single    Married     Separated    Divorced    Widowed

Number of Children Living in the home

Name             Age        
Name             Age        
Name             Age        
Name             Age        

Number of Children Living out of home

Name             Age        
Name             Age        
Name             Age        
Name             Age        

Others living in the home

Name             Age        
Name             Age        
Name             Age        
Name             Age        
Employment & Source of Income

Work Phone      
()  -

Job Title

Date Paid
Co-Applicant Employer

Work Phone 
()  -

Job Title

Date Paid
Total Net Income

Other Sources of Income (Retirement, Food Stamps, etc.)

* Have you ever filed Chapter 7 or Chapter 13 bankruptcy?


 What Happened?

* Present Housing Situation
Private Rental    Homeowner    Public Housing    Section 8 Housing    Other

   Loan Source:           VA    HUD    FmHA    FHA    Conv

* Services needed/ Major concerns:
List Complete Creditor Information Here
Creditors Account # # of
Past Due
Balance Amount of
Date of
Complete this section with your current monthly expenses.
Description   Present Monthly Expenditure Description   Present Monthly Expenditure
Mortgage/2nd Mortgage/          
Rent/Lot Rent   $ Secured Debt not in DSP $
Groceries   $ Ongoing Medical/Dental $
Utilities -      Clothing   $
Gas/Heat   $        
Electricity   $ Miscellaneous -    
Water/Sewer $   Tobacco   $
        Lunch @ work/school $
Alarm Service   $   Eating Out $
        Union/Professional Dues $
Communication -      Grooming   $
Telephone   $   Contributions $
Cell Phone $   Magazines/Papers $
Internet   $   Allowances $
Pager   $   Laundry/Dry Cleaning $
        Hobbies/Lessons $
Automobile -       Recreation $
Car Payment #1 $   Cable/Satellite TV $
Car Payment #2 $   Pet Care   $
Auto Insurance $   Books/Music $
Fuel/Parking $   Alimony/Child Support $
Maintenance $   Child Day Care $
        Trash   $
Taxes -         Rental Storage $
Real Property $   Tuition/Fees/Books/Loans $
Personal Property $        
      Savings/Investments $
Insurance -            
Health/Dental $ Other     $
Life Insurance $        
Homeowners/Renters $        

*Credit Card Information (-complete all fields)
    Payment Information
* Card Type:
* Card Number:
* Expiration (mm/dd/yyyy)
/ /
* Cardholder Name:

Please note: A $50 consultation fee will be charged to your card.

By pressing submit, you acknowledge that this form has been completed to the best of your knowledge. You also understand that your personal information is being submitted by a secure web server to a CCCS counselor.
If you have any questions regarding our use of your personal information please refer to our privacy policy.


Toll Free: (888) 381-3720
Mail: P.O. Box 2009, 316 Green Street
Fayetteville, NC 28302

Copyright © 2007