Name * First Name Last Name Email * Phone * (###) ### #### Street Address * APT # City * State * Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming County Gender * Male Female Prefer not to say Date of Birth * MM DD YYYY Are You a US Military Veteran? * Yes No Social Security Number * Race * American Indian Asian African American Caucasian Other Prefer not to say Ethnicity * Hispanic or Latino Not Hispanic or Latino Prefer not to say Marital Status * Married Single Divorced Widowed Prefer not to say # of Dependents 0 1 2 3 4 5 6 7 8 9 10+ Yearly Income * $ Highest Level of Education * Some High School GED High School Diploma Some College Associate's Degree Bachelor's Degree Master's Degree Ph.D or Higher Do You Live in a Rural Area? * No Yes Housing Status * Own Rent Live with family Housing Goals * Spouse Name First Name Last Name Spouse Phone (###) ### #### Bank of America Representative * If not applicable, type N/A Privacy Policy Financial Hope Credit Counseling Services is committed to ensuring the privacy of individuals and/or families who have contacted us for assistance. We realize that the concerns you bring to us 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. Your non-public personal information, such as your total debt information, income, living expenses, and personal information concerning your financial circumstances, will be provided to creditors, program monitors, and others only with your authorization and signature on the Housing Stability Counseling Program Counseling Authorization Agreement. We may also use anonymous aggregated case file information for the purpose of evaluating our services, gathering valuable research information, and designing future programs. Types of information that we gather about you: 1. Information we receive from you orally, on applications or other forms, such as your name, address, social security number, assets, and income; and 2. Information about your transactions with us, your creditors, or others, such as your account balance, payment history, parties to transactions, and credit card usage; and 3. Information we receive from a credit reporting agency, such as your credit history. Release of your information to third parties: 1. So long as you have not opted out, we may disclose some or all of the information that we collect, as described above, to creditors, where we have determined that it would be helpful to you, would aid us in counseling you, or is a requirement of grant awards that make our services possible. 2. We may also disclose any nonpublic personal information about you or former customers to anyone as permitted by law (e.g., if we are compelled by legal process). 3. Within the organization, we restrict access to nonpublic personal information about you to those employees who need to know that information to provide services to you. We maintain physical, electronic, and procedural safeguards that comply with federal regulations to guard your nonpublic personal information. Privacy Policy Acknowledgment * By checking below I acknowledge that I have read and accept the terms of the privacy policy. I Accept Date * MM DD YYYY Name * By typing my name below I acknowledge that I have read and accept the terms of the privacy policy. Authorization Form 1. I understand that Financial Hope Credit Counseling Services provides housing stability counseling, after which I will receive a written action plan consisting of recommendations for handling my situation, possibly including referrals to other housing agencies as appropriate. 2. I agree to allow Financial Hope Credit Counseling Services to pull my credit report at the time of intake. In lieu of a new credit pull, I agree to provide Financial Hope Credit Counseling Services with a copy of my credit report dated within 30 days of the intake date. 3. I understand that Financial Hope Credit Counseling Services receives Congressional funds through the Housing Stability Counseling Program (HSCP) and, as such, is required to submit client-level information to the Online reporting system and share some of my information with HSCP administrators or their agents for purposes of program monitoring, compliance, and evaluation. 4. I give permission for HSCP administrators and/or their agents to follow up with me between now and June 30, 2026, for the purposes of program evaluation. 5. I may be referred to other housing services of the organization or other agency or agencies as appropriate that may be able to assist with concerns that have been identified. I understand that I am not obligated to use any of the services offered to me. 6. I acknowledge that I have received a copy of Financial Hope Credit Counseling Services' privacy policy. You may choose to opt-out of certain disclosures: 1. You have the opportunity to "opt-out" of disclosures of your non-public personal information to third parties (such as your creditors), that is, direct us not to make those disclosures. 2. If you choose to "opt-out," we will not be able to answer questions from your creditors. If at any time, you wish to change your decision with regard to your "opt-out," you may call us at (214) 276-0235 and do so. I choose to opt-out Opt-Out Authorization Form Acknowledgment * By checking below I acknowledge that I have read and accept the terms of the authorization form. I Accept Date * MM DD YYYY Name * By typing my name below I acknowledge that I have read and accept the terms of the authorization form. Consent and Acknowledgement for use of Electronic Signature In an attempt to expedite the application process, Services of Hope/Financial Hope Credit Counseling Services asks that clients applying for services complete online forms and sign them electronically, thus replacing the handwritten form and wet signatures. Electronic Signature Agreement: By selecting the "I Accept" button, you are signing this Agreement electronically. You agree your electronic signature is the legal equivalent of your manually handwritten signature on this Agreement. By selecting "I Accept" using any device, means, or action, you consent to the legally binding terms and conditions of this Agreement. You further agree that your signature on this document (hereafter referred to as your "E-Signature") is as valid as if you signed the document in writing. You also agree that no certification authority or other third-party verification is necessary to validate your E-Signature and that the lack of such certification or third-party verification will not in any way affect the enforceability of your E-Signature or any resulting agreement between you and SOH/FHCCS. You are also confirming that you are the client authorized to enter into this Agreement. You further agree that each use of your email equates to your E-Signature and constitutes your agreement to be bound by the terms and conditions of these Disclosures and Agreement as they exist on the date of your E-Signature on this form. Consent to Electronic Delivery. By selecting the "I Accept" button, you specifically agree to receive, obtain, and/or submit any and all documents and information electronically. These documents and information will be collectively known as "Electronic Communications" and will include, but not be limited to, any and all current and future required notices and/or disclosures concerning services. You are acknowledging that you are able to use email and are able to retain Electronic Communications by printing and/or downloading and saving this Agreement and any other agreements, Electronic Communications, documents, or records that are signed using your E-Signature. You accept Electronic Communications provided via email as reasonable and proper notice for the purpose of fulfilling any and all rules and regulations and agree that such Electronic Communications fully satisfy any requirement that communications be provided to you in writing or in a form that you may keep. Definitions: • Electronic means technology having electrical, digital, magnetic, wireless, optical, electromagnetic, or similar capabilities. • Electronic Signature means an electronic symbol or process attached to, or logically associated with, a record and used by a person with the intent to sign the record. • Client File means the paper and/or electronic record pertaining to the client, including but not limited to the credit report and all documents used to determine the client's eligibility for services. Paper version of Electronic Communications: You acknowledge and agree that you may request a paper version of the verification worksheet or other documents by printing or saving a copy now. Revocation of electronic delivery: You have the right to withdraw your consent to submit communications via email at any time. You acknowledge that you are aware this action may delay the process of reviewing your file. If you wish to withdraw your consent, you will contact the Services of Hope/FHCCS immediately. Terms and Conditions: Clients are urged to carefully read the terms and conditions of this Agreement. Please keep all records relating to this agreement and print or make an electronic copy of the terms and conditions. I understand and agree to each and all of the Terms and Conditions in this Consent for Use of Electronic Signature Agreement. My electronic signature is legally binding. Consent of Electronic Signature * By checking below I acknowledge that I have read and accept the use of my E-signature. I Accept Date * MM DD YYYY Name * By typing my name below I acknowledge that I have read and accept the use of my E-signature. Disclosure Statement of Financial Educational Services Financial Hope Credit Counseling Services, formerly known as CCCS of Greater Dallas, Inc., is a non-profit U.S. Department of Housing and Urban Development (HUD)-approved housing counseling agency. I understand that Financial Hope Credit Counseling Services provides housing counseling and education, including bankruptcy counseling and education, budget counseling, and debt management plans. I am under no obligation to utilize or receive these services. Financial Hope Credit Counseling Services does not provide legal advice, financial planning, or tax services. There is no charge for Financial Hope Credit Counseling Services, with the exception of bankruptcy education, which has a fee of $50.00. Our educational programs are supported by grants, fees, and donations from various sources, including HUD, the National Foundation for Credit Counseling (NFCC), Capital One Bank, Bank of America, and other organizations. I authorize Financial Hope Credit Counseling Services to disclose, for reporting purposes, my ethnicity, race, income level, and education to HUD. I understand that authorized Financial Hope Credit Counseling Services staff or others with legitimate authority to monitor Financial Hope Credit Counseling Services practices may review my file for quality assurance, compliance, or research purposes. If such a review should occur, I understand that my identity will be kept confidential in any findings. Furthermore, at some time in the future, I may be contacted by a neutral third party to request an evaluation of Transformance's services. Financial Hope Credit Counseling Services agrees that my information will otherwise be kept confidential and used only for legitimate business purposes under applicable laws. I understand that Financial Hope Credit Counseling Services may utilize Team Teach volunteer instructors considered subject matter experts in the respective fields of mortgage lending, real estate, real estate inspection, insurance, and title for homebuyer education. Team Teach members provide in-depth knowledge in their respective fields and participate merely as representatives of their profession, not their individual companies. Furthermore, I understand that I am under no obligation to utilize their services and am free to select services from whomever I feel best meets my needs, including non-Team Teach members. If I am not satisfied with the services provided or if I want to make a complaint, I may try to resolve the issue with the staff member involved or their direct manager, providing them with specific information about my complaint. If this is not possible or if the issue is not resolved to my satisfaction, I may call 800-249-2227 to request a Client Complaint Form or to have the representative complete one for me. I will receive a written response within 10 business days of my call or the receipt of my written complaint. I may appeal this decision by writing to the President of Financial Hope Credit Counseling Services and will receive a written concluding decision within 15 days. I understand that Financial Hope Credit Counseling Services serves all members of the community. Financial Hope Credit Counseling Services does not discriminate in the selection or participation of clients in Financial Hope Credit Counseling Services programs or services on the basis of race, color, religion, gender, handicap, age, disability, sexual orientation, or ethnic origin. I understand that I am under no obligation to receive any other services or products offered by Financial Hope Credit Counseling Services and/or partnering entities. If requested, Financial Hope Credit Counseling Services may provide a list of referrals, containing at a minimum, when possible, three referrals in my direct service area. I understand that I am under no obligation to use recommendations and/or referrals made by the agency and that I am free to choose my services. I may terminate counseling and education services at any time. Disclosure Statement of Financial Educational Services Acknowledgement * By checking below I acknowledge that I have read and accept the Disclosure Statement of Financial Educational Services. I accept Date * MM DD YYYY Name * By typing my name below I acknowledge that I have read and accept the Disclosure Statement of Financial Educational Services. Thank you! We will contact your shortly.
