Pre-Discharge Education (PDE) Fee Waiver Policy

Policy

Form

If a client's 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), they 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 also .No documentation is needed from you.

In order to be reviewed for the fee waiver, you must complete our fee waiver form and submit copies of the following documentation (documents submitted will not be returned):

Proof of income for all household members:
- For all employed household members: Provide most recent 2 months of paystubs.
- For social security/social security disability income: Provide award letter or bank statement showing deposits.
- For self employed: Provide most recent year's tax return and 2 most recent bank statements.
- For child support: Provide 2 most recent bank statements.
Number of individuals in the household.
If your waiver request is based on pro bono attorney services, you need to provide us with a letter or email from your attorney stating they are providing legal services at no charge.
An email address, phone number or mailing address so we can contact you regarding our decision on your fee waiver application.

You may submit these materials through secure file attachment on the following page

By email (send proof of income or pro bono confirmation as scanned attachments), to contactus@ccoacares.com
Fax to 479-521-9200.
By mail (do not send original documents, as we will not be able to return them). Mail them to:

CCOA
P.O. Box 10168
Fayetteville, AR 72703
Fax: 479-521-9200
Drop them off at one of our offices. Again, make photocopies, as we will not be able to return originals.

To be considered for a fee waiver, the above documentation needs to be received in full prior to your education class with CCOA.

Pre-Discharge Education(PDE) Fee Waiver Form

Name:*

Total number of people in your household:

Household Type:

Total household gross monthly income:

Employer:

Spouse's Employer:

Date Submitted:

Required documentation for Proof of income for all household members:

For all employed household memebers: Provide most recent 2 months of paystubs.
For social security/social security disability income: Provide award letter or bank statement showing deposits.
For self employed: Provide most recent year's tax return and 2 most recent bank statements.
For child support: Provide 2 most recent bank statements.

Once we process your request, what is the best way to notify you of our decision?:

Email (provide email address):*

Phone (Check best option/s)*

Cell Phone:

Best time to call:

Home Phone:

Best time to call:

Work Phone:

Best time to call:

Mailing Address:

Attachment:
Please attach your proof of income document.(file size limit 5M)

I have read and I understand the disclosures made above. Signature:

Printed Name:*

Signature Date:*

* fields are mandatory

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Pre-Discharge Education (PDE) Fee Waiver Policy