Bankruptcy Counseling Registration Email Address (Preferred) or Create a Login NameCreate a Password* Enter Password Confirm Password Strength indicator 8 characters minimum, at least one number and at least one letter. Your InformationFiling Status*Single (Individual Fee, Not Married only one person filing)Married Filing Jointly, Living in Same Household (Joint Fee, both spouses filing)Married Filing Jointly, Living in Separate Households (Individual Fee, separate registration is required)Married Filing Single (Individual Fee, Only one spouse filing)Marital Status*SingleMarriedFirst & Last Name* First Last Date Of Birth*Month123456789101112Day12345678910111213141516171819202122232425262728293031Year202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920Last 4 Digits of Social Security Number*Last 4 digitsSpouseSpouse First & Last Name* Spouse First Spouse Last Spouse Date Of Birth*Month123456789101112Day12345678910111213141516171819202122232425262728293031Year202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920Spouse Social Security Number*Last 4 digitsGeneral InformationDo you own Real Estate?*YesNoNumber Of Vehicles:*Please enter a number from 0 to 5.Reason For Filing*Reason For FilingStop ForeclosureEliminate Legal Obligation to Pay DebtsPrevent RepossessionReduce or Eliminate Medical BillsRecent Loss of EmploymentStop Harassment from CreditorsRestore or Prevent Utility ShutoffStop Wage GarnishmentsChallenge Claims of Fraudulent CreditorsDeclined To AnswerWho will need to receive a certificate?* Myself My Attorney How would you like to receive the certificate?* Email Fax US Mail How would you like your attorney to receive the certificate?* Email Fax AddressAddress* Street Address City StateAlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code ContactPhone*The best number to reach you at.Cell PhoneFaxEmail AttorneyAttorney NameAttorney Email Attorney PhoneAttorney Fax(Optional code provided to you by your attorney) Disclosure DISCLOSURE STATEMENT Alliance is a non-profit organization dedicated to providing professional personal finance education, confidential counseling, and debt reduction programs. Clients have the opportunity to negotiate an alternate payment schedule for unsecured consumer debts and Alliance can provide this service. Counseling and education are available in person and by phone; additionally, education is available through the Internet. Services are available to anyone without regard to race, religion, national origin, gender, age, or ability to pay. All client information is held in strict confidence by Alliance in compliance with the Gramm-Leach-Bliley Privacy Act, except as authorized for release by the client, or as may be required from the United States Trustee. FUNDING SOURCES - Alliance receives the majority of its funding from the following sources: • Fees paid by clients for counseling services and education programs offered to the public. • Grants from private foundations and corporations who support our counseling and educational services and programs, and from government agencies. • Voluntary "fair share" contributions from some creditors related to debt management plans administered by Alliance. • Alliance does not pay or receive fees or other consideration for the referral of clients. COUNSELOR QUALIFICATIONS - All counselors are Alliance employees and most work full-time for the organization. Counselors obtain financial counseling certification through an approved third-party institution prior to providing counseling. Counselors comply with all continuing education requirements necessary to maintain certification. Only certified counselors are allowed to provide the required counseling and education, and to issue the Certificate of Completion. IMPACT ON CREDIT REPORT - Alliance does not disclose or provide, to a credit reporting agency, information concerning whether an individual client has received or sought credit counseling or instruction concerning personal financial management from the organization. Bankruptcy has a negative impact on a credit profile and is reported for 7 to 10 years, in most cases. NO LEGAL OR TAX ADVICE - Although a counselor may answer general questions about bankruptcy, Alliance does not provide legal or tax advice. If legal or tax advice is needed, you should seek the appropriate assistance from a qualified attorney or tax professional. LIMITED ENGLISH PROFICIENCY - Individuals who do not speak English as their primary language or who have difficulty understanding English, may request communication in another language at no charge. Alliance will provide communication in the requested language if it has a counselor or translator available, otherwise it will promptly provide a referral to another appropriate provider. COST OF SERVICES - Alliance charges fees for some services to cover the cost of providing the service. These fees include any postage, shipping, handling, and materials. The fee is due and payable at the time of the service. We accept VISA or MasterCard branded debit cards, Money-Gram, money orders and cashier checks. POWERS OF ATTORNEY - Powers of Attorney are not accepted by Alliance. Please contact your attorney or Bankruptcy Administrator in regards to the Voluntary Petition for Individuals Filing Bankruptcy - Official Form 101. FEE SCHEDULE: Pre-Petition Budget Briefing Online $19.00 Individual $19.00 Joint Telephone $49.00 Individual $49.00 Joint FEE SCHEDULE: Pre-Discharge Debtor Education Online $19.00 Individual $19.00 Joint A review of your circumstances during the budget briefing may determine that you are eligible for a reduced or waived fee. For example, Alliance will reduce or waive the fees for those whose household income is less than 150% of the estimated poverty threshold for their applicable family size as published by the Bureau of the Census. The fee may also be reduced or waived based on the debtor's budget analysis or other mitigating criteria. See details here. CERTIFICATE OF COMPLETION - Alliance is approved to issue a certificate evidencing completion of a credit counseling briefing and/or personal financial management course in compliance with the Bankruptcy Code. Approval does not endorse or assure the quality of a provider's services. Alliance determines when a client's counseling/course has been completed, which includes a minimum duration of 60 minutes for the budget briefing session, and 120 minutes for the debtor education course. Alliance will provide an appropriate Certificate of Completion to each individual no later than one business day after completing the budget briefing session, and no later than three business days after completing the debtor education course. Certificates are issued regardless of ability to pay. The certificate issued to you by Alliance will expire 180 days from the date of certification. I have Read and Agree with the Disclosure Statement:*ChooseYes I agreeNo I disagreeElectronic Signature*By typing your name in the box on the right, you are effectively signing this Disclosure Statement. Your name in the box signifies you understand that it constitutes as your signature.Spouse's Electronic Signature*By typing your name in the box on the right, you are effectively signing this Disclosure Statement. Your name in the box signifies you understand that it constitutes as your signature.Bankruptcy Case Number*CourseCourse* Price: $19.00 Total $0.00 Credit Card * American ExpressDiscoverMasterCardVisa Card Number CVV Expiration Date Postal Code Credit Card* American ExpressMasterCardVisa Card Number Month010203040506070809101112 Year20202021202220232024202520262027202820292030203120322033203420352036203720382039 Expiration Date Security Code Cardholder Name Card Holders Billing AddressSameDifferentAddress Street Address City AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code By clicking next you are about to process a debit/credit card payment in the amount of $19 This iframe contains the logic required to handle Ajax powered Gravity Forms.
