Pre-Discharge Education Affidavit

Disclosure & Affidavit Form for Pre-Discharge Bankruptcy Education Client

(Last revised: February 2023)

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** BY LAW, YOU MUST FIRST HAVE PRE-BANKRUPTCY COUNSELING AND FILE FOR BANKRUPTCY BEFORE YOU TAKE YOUR BANKRUPTCY EDUCATION!

We understand that you are contacting us because you have filed for bankruptcy and require financial education (Pre-Discharge Education) to discharge your bankruptcy. Credit Counseling of Arkansas (CCOA) has provided consumer financial education since 1995. CCOA uses the American Center for Credit Education's "Money In Motion" Pre-Discharge Education materials. We are approved to provide the education online and to issue certificates in compliance with the Bankruptcy Code to consumers who filed bankruptcy in Arkansas, Missouri, and Oklahoma. Approval does not endorse or assure the quality of a Provider’s services.

Our agency is accredited by the Council on Accreditation - an independent, third party organization that reviews and monitors organizations working in the social service field. We are a not-for-profit agency, organized to operate as a provider of educational services in accordance with Section 501(c)(3) of the IRS code.

The cost of the "Money In Motion" Pre-Discharge Education class is $50 for an individual, $60 for a couple. This includes online instruction and any further assistance you may need. We can take payment in cash (exact change only), cashier's check, money order, personal check or by debit card. The course is offered to you without regard to your ability to pay. If your household gross monthly income is 150% or less than the poverty guidelines provided by the U. S. Department of Health and Human Services ` (adjusted for family size), you are eligible for a fee waiver. CCOA will also waive the fee if your attorney is providing services pro bono. If you did your Pre-Filing Counseling (PFC) with us in the past 6 months and we waived that fee, we will automatically waive your PDE fee, too - no financial documents are needed from you.

To apply for the fee waiver, simply provide us this information:

If you appear to be eligible for the waiver, we will ask you to fill out the Fee Waiver Form and submit the appropriate documentation.

In order for us to effectively serve you, it is important that you provide us with information that is accurate and complete. You will only receive certificate if you complete the course. Upon completion of the course, CCOA is obligated to provide a certificate of course completion to you promptly within three business days. You and your attorney are responsible to file the certificate with the court in a timely manner. There is potential disclosure of your information to the Executive Office of United States Trustees (EOUST) in connection with the United States Trustee's oversight of CCOA, or during the investigation of complaints, during on-site visits, or during quality of service reviews. A Spanish version is available of the "Money In Motion" online bankruptcy education.

CCOA's Director of Education, Mark Foster, M.S., Certified Consumer Credit Educator (CCCE), oversees the Pre-Discharge Education program. He has over 25 years of experience in financial education.

Call 1-800-889-4916 or (479) 521-8877 or visit www.CCOAcares.com to register for the online education.

CCOA does not pay or receive fees or other consideration for the referral of debtor students to CCOA. CCOA is approved to issue certificates evidencing completion of a personal finance management instructional course in compliance with the bankruptcy code. Approval does not endorse or assure the quality of a Provider's services. EOUST has only reviewed the provider's counseling and instructional course and has neither reviewed nor approved any other services CCOA may offer.

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Be sure to include:

• Payment ($50 for an individual, $60 for a couple) of cashier’s check, money order, or personal check. Or call us to do a debit card payment or for us to invoice your attorney.Cash accepted in-person only (exact change only).
• Address for communication:

  CCOA
  P.O. Box 10168
  Fayetteville, AR 72703
  Fax: 479-521-9200

By signing this form you certify the following:

I certify that all the information on this affidavit is true, correct and complete, and made in good faith. I also certify that I personally will complete the education program. I understand that knowingly making a false or fraudulent statement or misrepresentation about my identity or completion of the education program is a violation of the requirements of Federal Law. I have read and fully understand the above. I also understand there is potential disclosure of my client/debtor information to the Executive Office of United States Trustees."

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