Form xxxx Credit Counseling Application

OMB No. 1105-0084 Approval Expires 06/01/2009

U.S. Department of Justice
Executive Office for United States Trustees
APPLICATION FOR APPROVAL AS A NONPROFIT BUDGET
AND CREDIT COUNSELING AGENCY
An application package is complete if all questions/items have been responded to and copies of
the documents requested in the application are attached. Failure to file a complete application
may result in the delay or denial of the application. If additional space is required to complete an
answer, attach a separate page with the name of the Agency, the federal tax identification number,
and the question number indicated on the top, right-side of the page.
Section 1. General Information Concerning the Agency
1.1

Name of Agency:_______________________________________________________________

1.2

Federal Tax Identification Number of Agency:_____________________

1.3

United States Trustee assigned Agency number (if previously approved):__________________

1.4

Additional names currently being used, including any d/b/a:

1.5

Primary business address:
Street address:

1.6

Mailing address: (if different)

Telephone No.:_________________________ Fax No.:_______________________________
Website:______________________________

1.7

Principal contact for the Agency:
Name:_______________________________ Title:_______________________________
Email address: ______________________________________________________________
If different then above:
Telephone No.:_____________________ Fax No.:_____________________________
Mailing address:

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(April 2006)

1.8

Agency is a(n):

_____ Corporation
_____ Institute of Higher Education
_____ Partnership
_____ Limited Liability Partnership
_____ Limited Liability Corp. _____ Other _____________________

1.9

State of organization: __________________

1.10

Complete and attach the following to the application:

Date of organization: _____________________

•

Appendix B: Judicial Districts.

•

Appendix C: Counseling Methods and Business Locations.

Section 2. Status as a Nonprofit Organization
2.1

Identify the Agency’s basis for nonprofit status (e.g., Section 501(c)(3) status under the Internal
Revenue Code) and state the Agency’s nonprofit purpose.

2.2

List all former names used other than those listed on questions 1.1 and 1.4. Include any f/k/a
and street and mailing address(es) the Agency has used in the last three years.

2.3

Identify the current officers. Provide their name, office title, principal occupation, amount of
direct or indirect compensation from the Agency during the last 12 months, and state whether
they have ever been convicted of a felony or a crime involving fraud, dishonesty, or false
statements. Attach a Curriculum Vitae for each officer who has served less than one year.

2.4

Identify the former officers who served within the last three years. Provide their name, office
title, terms of office, and state whether they have ever been convicted of a felony or a crime
involving fraud, dishonesty, or false statements and the reason for their departure from the
Agency.

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(April 2006)

2.5

Identify the current directors/trustees. Provide their name, street address, principal occupation,
current employer, amount of direct or indirect compensation from the Agency during the last 12
months, and state whether they have ever been convicted of a felony or a crime involving fraud,
dishonesty, or false statements. Attach a Curriculum Vitae for each director/trustee who has
served less than one year.

2.6

Identify the former directors/trustees who served within the last three years. Provide their
name, term of office, street address, employment experience, and state whether they have ever
been convicted of a felony or a crime involving fraud, dishonesty, or false statements.

2.7

Identify each individual (independent contractor) or entity that performs counseling services on
behalf of the Agency or regularly refers clients to the Agency. Provide each individual or entity’s
street address, mailing address, telephone number, fax number, email address, and Internet
website, if any. Attach any contracts or agreements that are currently in effect.

2.8

Provide the names of all individuals or entities with whom the Agency conducts business or has
conducted business within the last two years where the individual or entity is an affiliate,
subsidiary, or related. (A related entity includes a business in which an officer, director,
employee or relative of an officer, director or employee of the Agency owns, manages, controls
or holds, directly or indirectly, a 20 percent ownership or financial interest in the business.)
Attach any contracts or agreements that are currently in effect or were effective during the last
two years.

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(April 2006)

Section 3. Quality, Experience, and Background in Providing Credit Counseling Services
3.1

How long has the Agency been in business?

3.2

How long has the Agency provided credit counseling services? _____Years

3.3

Disclose the total number of clients counseled by the Agency within the last 12-month period.

3.4

If offering debt management plans, how long has the Agency offered debt management plans?
_____Years
_____Months

3.5

Disclose any memberships with credit counseling associations.

3.6

Disclose any accreditation(s) or certification(s) by accrediting or certifying organization(s) (e.g.,
the Council on Accreditation).

3.7

If, at any time during the last five years, the Agency’s accreditation or certification was revoked,
suspended, or lapsed, disclose when and why.

3.8

List each state in which the Agency is licensed or certified to conduct business. For each state
identified in response to this question, identify the state regulatory body that issued the license or
certificate and the license or certificate number, if any.

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_____Years

_____Months
_____Months

(April 2006)

3.9

List all business related legal actions, proceedings, investigations, arbitrations, mediations, audits
by federal or state agencies, and potential bond or other claims in which the Agency or any
officer, director, trustee, employee, or agent of the Agency is a party, pending or adjudicated,
within the last three years, and the outcomes.

3.10

Disclose any prior or ongoing disciplinary or enforcement action by any applicable licensing,
registration, or certification authority, court, or regulatory body against the Agency, or any
officer, director, trustee, employee, or agent of the Agency, within the last three years.

3.11

If the Agency fails to meet the two-year business requirement, but currently employs in each
location that serves clients at least one office supervisor with experience and background in
providing credit counseling for no less than two of the last three years, then attach the following
to the application:
•

the Curriculum Vitae of each supervisor describing the supervisor’s experience and

educational background;

•

a business plan; and

• the current year’s pro forma financial statements and cash flow projections (including, but not
limited to, balance sheets, profit and loss statements, and statements of cash flow).
3.12

Attach the annual audited financial statements prepared in accordance with generally accepted
accounting principles for the preceding two years. If no audited financial statements were
prepared then provide unaudited financial statements.

3.13

List and provide any written correspondence to the Agency from the Internal Revenue Service
within the last three years that addresses issues relating to 501(c)(3) tax status determination,
examination, compliance or audit, such as a letter indicating Agency’s credit counseling activities
are consistent or inconsistent with their tax exempt status as of a certain date, a “no-change
advisory”, a closing agreement or notice of a referral or a revocation of the Agency’s exemption.
If the Agency identifies any affiliated business or subsidiary that is listed in Question 2.5 and that
entity receives any such written correspondence for the same period from the IRS about its’
501(c)(3) status, list and provide the documentation as cited above.

Section 4. Counseling Services and Fees
4.1

State the average length of time spent with clients during a credit counseling session. _______

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(April 2006)

4.2

If providing telephone or Internet credit counseling services, describe the Agency’s experience
and proficiency in providing services over the telephone and Internet and explain (i) how the
counseling is designed and presented, (ii) how the Agency verifies the identity of the person
receiving the counseling, (iii) how the Agency verifies that the client completed the counseling as
it was designed, (iv) how the Agency verifies the identity and completeness when spouses receive
joint counseling, and (v) how a certificate of counseling will be provided to the client.

4.3

List all other counseling services that the Agency provides.

4.4

For the last two years, list all individuals or entities that the Agency refers clients to for services
related to financial matters and provide the name, address and telephone number of each
individual or entity, and a description of the services provided by each individual or entity.
Attach any contracts or agreements currently in effect.

4.5

Attach original or copies of the following to the application:
•

Any forms used in relation to the counseling services. Include information used to analyze
the (i) client’s current financial condition, (ii) factors that caused the current financial
condition, and (iii) plan to respond to the current financial problems without incurring
negative amortization or an increase in debt.

•

If the Internet is a component of a counseling session, provide a copy of all computer screens
viewed by the client.

•

A sample of the contract(s) or agreement(s) entered into with clients for counseling services.

•

Fee schedule or suggested contribution schedule for all fees and contributions to be paid by
client.

•

The Agency’s policy with regard to the availability of services for free or at a reduced rate
based on a client’s ability to pay.

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(April 2006)

Section 5. Qualifications of Counselors
5.1

Complete and attach Appendix D: Matrix of Current Counselors, for each location listed on
Appendix C that will be staffed by counselors providing credit counseling services to clients.
Enter the counselor’s name in the employee box and complete the information as instructed.

5.2

Attach originals or copies of any written standards, manuals, procedures, scripts, outlines, or
guidelines provided to employees who provide credit counseling services.

Section 6. Administration of Debt Management Plans and the Safekeeping and Payment of Client
Funds (To be completed only by Agencies offering debt management plans)
6.1

Disclose the number of debt management plans serviced within the last 12-months:_____________

6.2

Disclose the amount of funds distributed by the Agency to creditors within the last 12-month period:
$____________________

6.3

Will the Agency use a service provider (third-party) to facilitate the administration of its debt
management plans?
_____Yes _____No
If the answer to this question is “yes,” disclose the name, street address, telephone number, email
address, and fax number of the service provider; the full name of all principals of the service
provider; and attach a copy of the service agreement/contract between the Agency and the service
provider.

6.4

List the names and addresses of each bank or financial institution at which the Agency maintains an
operating account(s) and trust account(s) in which clients’ funds will be deposited and withdrawn to
pay respective creditors.

6.5

Attach the following to the application (this applies only to Agencies offering debt management
plans):
•

Most recent Form 990, Return of Organizations Exempt From Income Tax.

•

Original surety bond payable to the United States of America, if not previously provided, and
copies of any state bonds. (The Agency must provide the bond calculation.)

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(April 2006)

•

Proof of adequate employee bonding or fidelity insurance.

•

If the Agency has responded “yes” to 6.3 and the service provider is not approved by the United
States Trustee as a nonprofit budget and credit counseling agency, attach proof that the service
provider is specifically covered under the Agency’s surety bond or has a surety bond in a
sufficient amount to provide for the safekeeping of the Agency’s client funds, and a written
acknowledgment from the service provider wherein the service provider agrees to allow the
United States Trustee or his/her designee to audit the trust accounts maintained by the service
provider and to review the service provider’s internal controls and administrative procedures.

Section 7. Activity Report for Approved Agencies (To be completed only by Agencies who have
previously been approved by the United States Trustee and are seeking re-approval.)
7.1

Complete and attach Appendix E: Activity Report for Approved Agencies.

Section 8. Acknowledgments, Agreements, and Declarations
8.1

Attach an originally executed Appendix A, Acknowledgments, Agreements, and Declarations in
Support of Application for Approval as a Nonprofit Budget and Credit Counseling Agency.

8.2

Attach copies of all disclosure forms that will be provided to clients. These disclosure forms must
include information regarding funding sources, counselor qualifications, impact on credit reports,
costs of the program, and how such costs will be paid.

Section 9. Certification and Signature
I declare under penalty of perjury that I am authorized to complete this application on behalf
of the above named organization; I have examined the contents of the application, enclosures, and
other accompanying documents; the documents provided with this application are authentic,
complete, and accurate; and all representations are true and correct to the best of my knowledge,
information, and belief.
________________________________________

___________________________________

Signature of President, Chairman, Trustee, or Other Authorized Official

Type or Print Name of Signer

________________________________________

___________________________________

Type or Print Title of Signer

Date

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(April 2006)