CONSUMER CREDIT COUNSELING SERVICE OF CENTRAL OKLAHOMA INC.

Debt Management Plan Agreement PIN ____________________

Please read the following statements carefully so that you will understand the provisions of the Debt Management Plan. Your signature indicates your understanding of all provisions stated in each paragraph. For simplification the singular is used even when the plural may apply.

I understand I am engaging the professional services of Consumer Credit Counseling Service, (CCCS), to negotiate a repayment plan hereinafter referred to as the Debt Management Plan or “DMP” with my creditors. My DMP serves the dual role of helping me repay my debts and helping my creditors collect the money owed them; thus, I freely volunteer to abide by the provisions of this agreement as follows:

Deposits: I agree to make monthly deposits to my DMP with CCCS in the following manner:

1. Based on the information you provided, the best estimated deposit will be $ __________, which includes my monthly fee of $___________ to CCCS. The first deposit is due _______________. I understand that this deposit amount may be slightly adjusted due to final balance and payment calculations. I have the right to review and approved required payment changes prior to the start of the program.

2. Your first deposit which includes the one time set up fee of $40.00 will be $_______________. All future deposits will have the following deposit schedule.

Deposit __________________ Due __________ of each month

3. I agree to make all deposits by certified funds. This may include cashiers check, money order, automatic bank withdrawal, E-Check (pay by phone), or online bill pay. All funds should be made payable to CCCS. I understand CCCS will not accept cash or personal checks.

Consistent and Full Deposits: I understand the success of my DMP depends on my consistent and full deposits to CCCS. I further understand that those creditors who’s policy may allow a re-age (bring current) my account, will only do so two times in five years. If my account has already been re-aged twice, I may receive late fees. Furthermore, to stop the late fees I will need to catch up my payments.

Duration of DMP: I understand finance charges, fees or penalties imposed by creditors may increase my overall indebtedness as well as the length of time required to fully pay my creditors over and above the estimates provided by CCCS. Thus, my DMP could be extended to pay out accrued interest. I further understand that increasing my DMP deposit will reduce the amount of time to achieve completion of my DMP. Therefore, as it is in my best interest, I will make every effort to increase my deposit whenever possible.

Credit History: I understand participation in my DMP may affect my credit report either favorably or unfavorably according to my creditor’s policies with respect to the DMP and my payment history prior to and during my participation in the DMP. I understand CCCS does not report my payment activity to any credit reporting agency.

Termination of Agreement: I understand I can terminate this agreement for any reason or at any time by providing written notice to CCCS. This agreement can be terminated by CCCS for the reasons below. If CCCS or I terminate this agreement, any money left in my account will be paid to my creditors, unless otherwise required by law. I understand that if my DMP is terminated, it is my responsibility to notify my creditors.

1. Failure to make payments: I understand CCCS reserves the right to discontinue my DMP if I fail to make two consecutive monthly deposits in full. Creditor cooperation depends on consistent payments through CCCS. A DMP cannot be re-opened without re-counseling.

2. False information/pay on own: I understand this agreement can be terminated immediately by CCCS if it is found that I have provided any false information to CCCS, if I have paid creditors on my own, or if I fail to comply with any other provision, term, or condition of this agreement.

Creditors Rights: I understand my creditors voluntarily cooperate with CCCS in this debt repayment plan. I further understand that if I miss one or more deposits or make partial deposits, or for any other reason they deem appropriate, my creditors reserve the right to discontinue any concessions made to me under the DMP with respect to interest, penalties, and fees. I further understand nonpayment or partial payment may affect my credit rating negatively.

Box 1789, Bethany, OK 73008-1789 (405) 789-2227 1-800-364-2227 REV. 02/2010


Debt Management Plan Agreement, page two

Usage of Credit: I certify that all my credit cards have either been returned to the creditor, lost, destroyed or turned in to CCCS for disposal. Any exceptions have been discussed with my counselor. In the event there is no balance on an account, I will request that the creditor close the account. I further understand and agree that I will not apply for, nor will I accept from anyone more credit or assume any new debts without prior CCCS approval. I agree to allow CCCS to access my credit bureaus at any time during the DMP program.

Authorized Release: I instruct you to provide any information that I have given to you that may be requested by any creditor(s) to whom I owe money and who will be considering me for a Debt Management Plan. You may negotiate payments and due dates in my behalf. I also authorize you to obtain any financial information concerning me from my creditors, as CCCS deems necessary.

Other Provisions:

1. Complete file. I understand my DMP will not be opened until I supply all requested information to make my file complete. Any money I deposit with CCCS before file completion will be held until my file is complete.

2. Proposed payments. I understand my DMP is based on proposed payments. Thus my deposit balance is subject to change as creditors revise payment arrangements. Your counselor will provide you with a packet which will list your debts and the proposed payment. This packet will include total debt owed and total DMP debt.

3. Monitoring statements. CCCS agrees to send me periodic statements of payments made through CCCS. I agree to monitor my statements from creditors to verify that payments have been received and to notify CCCS of significant differences between the balances on creditor statements and CCCS statements. I understand I have the right to review my file in the presence of a CCCS staff member during regular business hours. I agree to send to CCCS a copy of the most current statement from each creditor at least once every three months.

4. Creditor statements. I hereby certify that all creditors listed on the DMP are only in the names of the person(s) listed on this DMP agreement and that no other parties are associated with these debts.

5. Legal advice. I understand though a counselor may answer questions about bankruptcy, CCCS does not provide legal advice. If legal advice is needed, I will seek the appropriate assistance.

6. Changes to agreement. I understand CCCS, at its discretion, may make changes to this agreement including increases in monthly service charges, by giving me thirty (30) days notice.

7. File review. I understand authorized CCCS staff or staff agencies, with legitimate authority to monitor agency practices, may review my file for quality assurance or compliance purposes. I also understand that officials with legitimate authority, for employment or security purposes, may review and verify account balances and my status with CCCS. If such a review should occur, I understand findings will be kept confidential.

8. Hold harmless. I hereby agree to hold CCCS, its employees, officers, directors, and agents free of liability from any claim, suit, action or demand made by any of my creditors and any other person, which in any manner may arise from any action or inaction taken by CCCS, or my creditors, in connection with any services rendered by CCCS for me.

9. Successful Completion of Plan. Upon completion of the plan and verification of zero balances with my creditors, I agree that any residual funds in the amount of $25.00 or less not be returned unless requested in writing to CCCS. Balances over $25 will be refunded to me.

I acknowledge I have read and understood each of the above provisions, terms, and conditions of this agreement. Both CCCS and I have received a copy of this agreement. CCCS and I agree there are no other agreements, promises, or representations, unless executed in writing between CCCS and me other than those contained in this agreement.

Client Signature Counselor

Printed Name Office

Co-Client Signature Date

Printed Name Client #

Box 1789, Bethany, OK 73008-1789 (405) 789-2227 1-800-364-2227 REV. 02/2010