Unified Privacy & Disclosure Agreement – All Housing Counseling Services
CCCSA = Consumer Credit Counseling Service of Alabama, Inc. (“Agency”)
HUD = Dept of Housing and Urban Development.
NFCC = National Foundation for Credit Counseling
CCCSA (“the Agency”) is an IRS 501(c)(3) nonprofit financial and credit counseling agency, certified by HUD as a
Local Housing Counseling Agency. All housing counseling services including homebuyer counseling, homeowner
financial counseling, High Cost Mortgage Counseling, foreclosure/default counseling, and reverse mortgage
counseling are provided or supervised by NFCC Certified Housing Counselors following policies and procedures as
outlined in the HUD Housing Counseling Handbook. By participating in our housing counseling program, you give us
permission to disclose any and all information collected from you, your credit report, and/or your creditors to HUD and
the NFCC for audit, program compliance, and grant funding purposes. You further agree to allow us to submit your
information to HUD’s Housing Counseling System (HCS) for storage on HUD’s servers for four years or as otherwise
required by HUD.
You may be referred to the other services provided by CCCS of Alabama (financial counseling, credit counseling,
bankruptcy counseling, debt management programs, or credit report counseling) or to other agencies as appropriate
that may be able to assist with particular problems that have been identified during your session. You are not
obligated to participate or utilize any services discussed and have the right to use or decline any referrals offered. Our
counselors receive no financial or other incentives for referrals or for your participation in any of our programs.
CCCSA receives funding from client paid fees, grants, contracts, program income, and donations. Fees for our
housing program are limited to $75 for homebuyer programs, $75 for High Cost Mortgage Counseling and $125 for
reverse-mortgage counseling. Homeowner financial counseling and foreclosure/default counseling are provided
without charge. When possible grant funds are used to waive or reduce fees for housing counseling services provided
that you agree to this disclosure, provide required information, and stay in touch until your case is closed.
Grant funding may include HUD grants, NFCC sponsored grants, grants from mortgage companies, grants from
lenders (credit card companies, loan companies, etc), and grants from state and local government agencies. Program
income may include voluntary contributions (called “Fair Share”) received from lenders participating in debt repayment
plans (additional agreements required) or lenders who provide grants to support financial literacy, counseling, and
education. Some lenders, including mortgage companies, are also willing to pay counseling fees for their customers.
We are happy to provide you with the source of funding we will use to help pay the cost of your services.
If you are participating in homeowner financial counseling, foreclosure/default counseling, or High Cost Mortgage
Counseling, you agree to provide truthful, complete, and accurate information regarding the sources and amounts of
all household income, all household residents, all mortgages in your name, all properties you own in whole or in part,
your mortgage history, your participation in other housing programs or other housing agencies, your expenses and
debts, and any legal actions (prior or pending) in which you are involved. For High Cost Mortgage Counseling, your
lender is required to provide certain documents before counseling and before closing or we will not issue you the
required certificate of counseling. We do not recommend high cost mortgages as it places your home at risk.
Our counselors will not contact your mortgage company on your behalf without a separate, signed agreement
specifically giving us your permission to do so. Counselors will help you evaluate your financial situation and consider
any available options that may help improve your financial situation. We cannot tell you if you will be approved for a
modification, refinance, or other lending action, but we can help you understand and fill out forms and provide
documents to your mortgage company as may be appropriate. If the information you provide us indicates that you
cannot afford to keep you home, we will help you look at non-retention options as well. Ultimately, what you decide to
do is up to you. We will help you consider options and put together a written action plan to meet your goals.
If you are participating in our homebuyer program and need a Certificate of Completion as described by the HUD
Handbook, the following will be required:
 All persons included on the proposed mortgage must attend counseling and training sessions.
 You must provide a valid photo ID or other proof of identity.
 You must provide accurate and complete information to counselors and you must fully participate and complete
training exercises and forms.
 You must provide a copy of any Good Faith Estimates, real estate contracts, and the HUD-1 Closing Statement, if
you purchase a house.
 Respond to our calls, emails, and letters promptly and stay in touch with your counselor until your file is closed.
 Pay any required fees unless you are approved for free service under any available grants.
 Acknowledge receipt (by signing below) of the following documents on the pages that follow: “For Your Protection,
Get a Home Inspection”, “10 Questions to Ask Your Home Inspector”, CCCSA Client Bill of Rights, CCCSA
Complaint Resolution Process, and CCCSA Discrimination Policy. (you do not need to print and return these docs)
In considering the purchase of a house, we strongly recommend:
 That you not purchase a house unless you are prepared to start saving regularly for the cost of upkeep and
maintenance of the property;
 That you include provisions for a home inspection by a qualified home inspector as a contingency in your purchase
contract and that you read the inspection report yourself before releasing the contingency.
 That you include your approval for Down Payment Assistance or any other assistance program you are
participating in as a contingency in your purchase contract,
 That you include provisions for your approval of a termite inspection, termite bond & survey as a contingency in
your purchase contract;
 That you shop and compare mortgage interest rates and costs from 3 different mortgage companies before
deciding which company to use for your mortgage application and that you consider FHA, VA, or USDA mortgages
as one of your options;
 That you include requirements for an appraisal of the property for at least the amount of the purchase price as a
contingency in your purchase contract;
 That you consider only fixed rate mortgages, preferably FHA or VA, and obtain loan estimates prior to making an
offer to purchase; and,
 That you make time prior to closing to read all closing documents and that you sign closing papers only after
reading, understanding, and agreeing to the terms contained therein.
While counselors may help you understand the benefits and liabilities of homeownership, we cannot and will not
provide legal, insurance, or tax advice nor will we recommend specific attorneys, tax advisers, mortgage companies,
real estate agents, insurance agents, or home inspectors.
Our job is to help you look at your options, based on the information you provide. Your job is to make your own
decisions and be responsible for those decisions. By signing below, you agree to all the terms we've discussed and
agree to hold our agency, employees, directors, counselors, and volunteers harmless from any claim, suit, action, or
demand by anyone as a result of the decisions you make based entirely or in part on the information we provide.
Client Signature ____________________________
Client Social Security #_______________________
Date_________________________
Client Date of Birth_____________
Spouse Signature ____________________________
Date________________________
Spouse Social Security #_______________________
Date of Birth_________________
Mortgage Company/Servicer:
_______________________________________
Loan Number:
_______________________________________
Property Address:
_______________________________________
_______________________________________
_______________________________________
Borrower’s Name
_______________________________________
Co-Borrower’s Name:
_______________________________________
Dear Sir or Madam:
In the interest of providing housing counseling under HUD/NFCMP Housing Counseling Programs, permission
is hereby given and a request is made to Consumer Credit Counseling Service of Alabama, Inc (CCCSA) and
the mortgage company listed above to disclose and exchange any and all information regarding the property,
mortgage, loan, and any other financial or non-public information contained in the files of either company. I
hereby release both companies of any liability for the release of information between the two parties by
employees, representatives, or management for the purposes providing mortgage assistance and counseling.
The name of my CCCSA counselor is: ____Roger A Knauff (334)-265-8545__________________.
Disclosures by either party may be by telephone, fax, mail, or electronic communication.
This permission extends until the earlier of 12 months from the date signed below or until both parties receive a
written notice that permission is withdrawn.
Sincerely,
______________________________
Borrower’s Signature
______________
Date
___________
SS (last 4)
_________________
Contact Phone
______________________________
Co-Borrower’s Signature
______________
Date
___________
SS (last 4)
_________________
Contact Phone
The information transmitted is the property of the Consumer Credit Counseling Service of Alabama, Inc.
(CCCSA, Inc.) and may contain confidential and/or privileged material. This information is solely intended for
the recipient. If the reader of this message is not the intended recipient, you are hereby notified that you have
received this information in error. Any review, dissemination or copying of this message or attached material is
strictly prohibited, unless authorized in writing by CCCSA, Inc. If you received this transmission in error, please
notify the sender immediately and delete and destroy all copies of this message immediately. Violators are
subject to all penalties as allowed by Federal law. Thank you.
Client's Income
Spouse's Income
Primary Job
Primary Job
# Checks Per Month
# Checks Per Month
Gross each Check
Gross each Check
Net each Check
Net each Check
Job #2
Job #2
# Checks Per Month
# Checks Per Month
Gross each Check
Gross each Check
Net each Check
Net each Check
Other Income (monthly)
Other Income (monthly)
Alimony
Alimony
Child Support
Child Support
Social Security / SSI
Social Security / SSI
AFDC
AFDC
Welfare
Welfare
Food Stamps
Food Stamps
VA Benefits
VA Benefits
Rental Property
Rental Property
Retirement Plans
Retirement Plans
Other
Other
Total Gross Income Client
$
-
Total Gross Income Spouse
$
-
Total Net Income Client
$
-
Total Net Income Spouse
$
-
Total Gross Household Income:
$
-
Total Net Household Income:
$
-
EXPENSES
Rent
Mortgage Company
2nd Mortgage Company
Home Equity Loan
Taxes & Insurance (if not in pmt)
Mobile Home Lot Rent
Other Housing
Alimony Payment
Child Support Payments
Other Legal Obligation
Electricity
Gas/Heating oil
Water & Garbage
Telephone - Land Line
Telephone Cell
Cable TV/Satellite
Internet Service (if separate)
1st Car Payment
2nd Car Payment
3rd Car, Motorcycle, ATV, Boat
4th Car, Motorcycle, ATV, Boat
Gasoline
Monthly Auto Insurance
Monthly Auto Insurance
Bus, Carpool, Parking, etc.
Maintenance (oil changes, etc.)
Tags & Taxes
Groceries - Family of
Work & school lunches, snacks, etc.
Dining out
Paper products, cleaning supplies, sundries
Other Food Expense
Life Insurance - Client
Life Insurance - Spouse
Life Insurance - Other
Health Insurance (NOT Payroll deducted)
Monthly
Amount
Other Policies (cancer, burial, etc.)
Monthly
Amount
Doctor Visit Co-pays
Prescriptions
Other Medical
Hair care, personal items
Alcohol and Tobacco
Pet Expenses (Vet, etc.)
Church & charitable organizations
Gifts (birthdays, Christmas, etc.)
Clothing (Replacement needs only)
Children's Day Care
Allowances
Children's activities (sports, dance, etc.)
Club/Union dues (not payroll deducted)
Subscriptions Newspapers, magazines, etc.
Video Rentals, Netflix, etc
Postage
Bank/Credit Union charges
Dry Cleaning, Laundry
School tuition, books, etc.
Other
Other
Enter debt information on next page.
Page 2 of 3. Enter debt information on page 3
This completed form can be faxed to CCCS of Alabama, Inc. 334-265-5926. Please include your name,
address, and a phone number where you can be reached with questions.
DEBT INFORMATION
Company Owed
Balance
APR
We cannot provide you with a certificate if we do not have debt information.
We will not issue you a certificate if we have no way to contact you with questions.
Monthly
Payment