Request For Services

CCCS Preliminary Intake Form

  • Click here to download the Preliminary Intake form as a PDF file

    Click here to download the Preliminary Intake form as a PDF file* or complete the form online below.
    *The file can be downloaded, completed on your computer, and submitted to us through a secure link without printing!
    Adobe Reader, a free program, is required to open the above PDF file. Click here to download Adobe Reader.

  • Online Intake Form

    If you are completing the intake form below, please click on the following link to the Counseling Services Statement & Privacy Policy so that you will understand the procedures for the counseling session and with whom the information on this form may be shared. Your continuation and/or submissions in this process indicate your understandings of these provisions:

Statement and Privacy Policy *REQUIRED*
How did you find out about us? *REQUIRED*
If Other, please specify
YOUR PERSONAL INFORMATION
Last Name *REQUIRED*
First Name *REQUIRED*
Middle Initial
Birthdate *REQUIRED*
mm/dd/yyyy
Primary phone *REQUIRED*
Unlisted *REQUIRED*
Work Phone
Is it okay to call you here?
Email Address *REQUIRED*
Street Address *REQUIRED*
City, State, Zip Code *REQUIRED*
County *REQUIRED*
What brings you to CCCS? *REQUIRED*
*Call the Mortgage Counseling Department at 717.397.5182 ext. 162 immediately to set up a face-to-face appointment.
**Our agency does not provide bunkruptcy certification. Call 1-800-388-2227 for a list of agencies that do.
Housing Status *REQUIRED*

*Please complete if you are buying or own your home

Present value of property
$
Balance of 1st mortgage
$
Balance of 2nd mortgage
$
Balance of home equity loan
$
Are you behind in your mortgage payments? *REQUIRED*
How many months?
Do you have other real estate?
Value
$
Marital Status *REQUIRED*
How long? *REQUIRED*
# of children at home *REQUIRED*
Other residents
Partner's Full Name
First, Middle, Last
Spouse's Birthdate
mm/dd/yyyy
Your Employer *REQUIRED*
Company Name & Address (Street, City, State, Zip Code)
Partner's Employer
Company Name & Address (Street, City, State, Zip Code)
List year and make of vehicles owned or leased
List all recreational vehicles

* * *

Now we need to see what your monthly income and expenses look like.

WHAT YOU MAKE AND WHAT YOU SPEND

The next section will guide you through listing what you bring in and where your money goes each month. Be realistic when you fill in the numbers. If you can't be realistic, be conservative - underestimating your income and overestimating your expenses. Have all your bills, receipts, bank statements, etc. in front of you and have your spouse or partner help.

You'll need to get all your figures in monthly terms. If the item comes:
• weekly, multiply by 4.33
• every other week, multiply by 2.15
• twice a month, multiply by 2
• quarterly, divide by 3
• annually, divide by 12
• If you don't know when it comes, add it up for the year and divide by 12.

For income, we need to know your net income, that is the amount of money you take home after taxes and benefits have been deducted by your employer.

- Tell us how much you make each month (net income)
Full-time job *REQUIRED*
Part-time job *REQUIRED*
Other Jobs *REQUIRED*
Government Benefits *REQUIRED*
Child or Spousal Support *REQUIRED*
Other Sources *REQUIRED*
Total Monthly Income *REQUIRED*
- Tell us what you spend each month
Rent or Mortgage *REQUIRED*
Taxes *REQUIRED*
Home Maintenance *REQUIRED*
Homeowners or Renters Insurance *REQUIRED*
Electricity *REQUIRED*
Gas/Oil/Propane *REQUIRED*
Telephone *REQUIRED*
Water/Sewer/Trash *REQUIRED*
Groceries & Supplies *REQUIRED*
Work and/or School Lunches *REQUIRED*
Dining Out *REQUIRED*
Gasoline for Vehicle(s) *REQUIRED*
Car Maintenance *REQUIRED*
Auto Registration & Inspection *REQUIRED*
Auto Insurance *REQUIRED*
Public Transportation *REQUIRED*
Barber/Beauty Shop *REQUIRED*
Allowance & School Expenses *REQUIRED*
Cosmetics/Toiletries/Baby Supplies *REQUIRED*
Tobacco/Alcohol *REQUIRED*
Medical Expenses *REQUIRED*
Health Insurance *REQUIRED*
Clothing *REQUIRED*
Laundromat/Dry Clean *REQUIRED*
News Magazine Subscription *REQUIRED*
Gifts: Xmas, Birthdays, Anniversaries, etc. *REQUIRED*
Donations *REQUIRED*
Cable TV *REQUIRED*
Videos & Movies *REQUIRED*
Hunt/Fish/Sports/Crafts/Hobbies *REQUIRED*
Gambling *REQUIRED*
Pets *REQUIRED*
Child Care *REQUIRED*
Alimony/Child Support *REQUIRED*
Life/Disability Insurance *REQUIRED*
Vacations/Miscellaneous *REQUIRED*
Total your monthly expenses here *REQUIRED*

* * *

Finally, let's look at...

YOUR DEBTS

All your debts must be listed below before an appointment can be scheduled.

Please begin a new line for each listed debt *REQUIRED*
Remember to include car loans and leases, credit cards, lines of credit, consumer loans, medical bills, tax and utility arrears (past due amounts), student loans, and other debts you owe. The prefix is the first six digits of the credit card number.
__ Include: # Debt, Creditor Name, Prefix (1st 6 digits), Type of Debt, APR, Balance, Monthly Payment
How did you get into this situation? *REQUIRED*
If Other, please specify

* * *

COMPLETING THE INTAKE PROCESS

Once we have your information, we will contact you to set up your free appointment.

Please choose how you want us to contact you to set up the appointment *REQUIRED*

If by phone...

...which phone?
...which times?
...which days?
If Other Phone, please list the number & specify where we are calling

You must bring the following documents to your CCCS appointment:
• Proof of your income:
- Three Pay Stubs or
- Your bank statement if you have direct deposit or
- Statement of benefits if you are receiving unemployment
• Your Recent Household Bills
• Social Security Numbers for you and your partner
• Recent Account Statement from all your Creditors
• A Current Credit Report
• Available free from annualcreditreport.com
- or
• By mailing to: Annual Credit Report Request Service PO Box 105281 Atlanta GA 30348-5281

Remember:
• No children at the time of the appointment;
• Expect a 2-hour appointment.

Cancellation Policy- You must cancel 24 hrs before scheduled appointment; otherwise appointment is classified as a "no show". There will be a $20 fee to reschedule.

P.S. If you still have questions about the CCCS process or filling out this form, you may call 717-397-5182, extension 451. Leave your question on the answering service with your phone number and the best time for someone to return your call. Or you can email your questions to cccs@tabornet.org.

Consumer Credit Counseling Service of Central Pennsylvania (CCCS of Central PA)
A division of Tabor Community Services
308 East King Street
P.O. Box 1676
Lancaster, PA 17608-1676
(717) 397-5182
fax (717) 399-4127
(800) 788-5062 (in Pennsylvania only)

When you click "Send Now", you will be brought to a confirmation page and receive a confirmation email letting you know that this application has been submitted successfully.