PAYDAY LOAN COUNSELING REGISTRATION

Step 1 of 6

Email Address (Preferred) or Create a Login Name*
Create a Password*
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8 characters minimum, at least one number and at least one letter.

Loan Type*
- Single 25$ (Individual loan)
- Married 35$ (Both have seperate loans)
Your Address
Address*
Street Address City State ZIP Code
Your Information
First & Last Name*
First Last
Date Of Birth*
Last Four Digits of Social Security Number*

Last 4 digits
Spouse Information
Spouse First & Last Name*
Spouse First Spouse Last
Spouse Date Of Birth*
Spouse Last Four Digits of Social Security Number*

Last 4 digits

Completion Date*
MM slash DD slash YYYY

The date you plan on having the counseling session completed by.
Your Contact Info
Phone*
The best number to reach you at.
Cell Phone
Fax
Email*
Payday Loan Lender Info
If you have more than one payday loan, please email the additional documents to counseling@knowdebt.org

Florida Loans Only – Please refer to documents given by the lender labeled “60 Day Grace Period Deferment Agreement”.
Lender Name*
Lender Address
Street Address City State ZIP Code
Lender Fax or Email*
Lender Phone*
Loan Identification*

( may be loan #, agreement #, Customer # )
7th Day Ends Date*
MM slash DD slash YYYY

Refer to documents received from lender. Florida loans only.
60th Day Ends Date*
MM slash DD slash YYYY

Refer to documents received from lender. Florida loans only.
Loan Balance
Payday Loan Lender Info For Spouse Loan
Please refer to documents given by the lender labeled 60 Day Grace Period Deferment Agreement”.
Lender Name*
Lender Address
Street Address City State ZIP Code
Fax or Email*
Lender Phone*
Loan Identification*

( may be loan #, agreement #, Customer # )
7th Day Ends Date*
MM slash DD slash YYYY

Refer to documents received from lender.
60th Day Ends Date*
MM slash DD slash YYYY

Refer to documents received from lender.
Loan Balance

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 Courts or similar authorities.
1. Clients cannot register for online session after 12 pm on their 7th day. Please call Alliance to allow a counselor to assist with the registration process.
2. No refunds granted after Letter of Engagement has been faxed/email to the lender.
3. You are responsible for contacting your lender to verify receipt of the Letter of Engagement and Certificate of Counseling.
The counseling session could take up to 1 hour/60 mins.

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.

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.

FEE SCHEDULE: Payday Loan Sessions Online $25.00 Individual $35.00 Joint Telephone $35.00 Individual $45.00 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.
I have Read and Agree with the Disclosure Statement:*
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.
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.
Course
Course*
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Credit Card *

American Express
Discover
MasterCard
Visa

Card Number
CVV
Expiration Date
Postal Code
Credit Card*

American Express
MasterCard
Visa
Supported Credit Cards: American Express, MasterCard, Visa
Card Number Expiration Date Security Code Cardholder Name
By clicking next you are about to process a debit/credit card payment in the amount of $25.
By clicking next you are about to process a debit/credit card payment in the amount of $35.
Card Holders Billing Address
- Same
- Different
Address
Street Address City State ZIP Code

PAYDAY LOAN COUNSELING REGISTRATION

Step 1 of 6

Your Address

Your Information

Spouse Information

Your Contact Info

Payday Loan Lender Info

Payday Loan Lender Info For Spouse Loan

Disclosure Statement

Course