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Reverse Mortgage Specialist (RMS)                                                                    
                        How did you hear about this counseling agency:
Lender                                                                    
    

Your Mailing Address (The place where you'd like the C-Cert mailed to - if mailed)  

City                                              State                    Zip
    

Phone # (The best # to reach you)      Fax # (Where to fax the C-Cert to - if faxed)
                          Your Time Zone:
Alternate Phone Number (Optional)                                                                                                              
                                                             Eastern          Central        Mountain       Pacific
Email Address (Where to send the C-Cert to - if emailed)

Preferred Method of C-Cert Delivery to You                                    (C-Cert will also be mailed to client)
 Fax    Email    USPS    Any (doesn't matter)                
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Sorry, we cannot provide counseling services to the states of  MA, VT and NC at this time.
CCCS of SW GA - Consumer Credit Counselor Service of Southwest Georgia