xxxx CC Application Appendix A

Appendix A: Acknowledgments, Agreements, and Declarations in Support of
Application for Approval as a Nonprofit Budget and Credit Counseling Agency
(Application for Approval as a Nonprofit Budget and Credit Counseling Agency)

Name of Agency:
The Agency hereby assures and certifies compliance with all applicable federal statutes, regulations,
policies, guidelines, and requirements including, but not limited to, 11 U.S.C. §§ 109(h) and 111. The
Agency also specifically assures, certifies, and agrees that:
1.

It is in compliance with all applicable laws and regulations of each state, commonwealth, district, or
territory of the United States in which the Agency seeks approval from the United States Trustee.

2.

It is organized and operated as a nonprofit entity and has an independent board of directors, board of
trustees, or other governing body the majority of which (i) are not employed by such Agency, and (ii)
do not directly or indirectly benefit financially from the outcome of the counseling services provided
by such Agency.

3.

It will comply with the policies and directives of the United States Trustee and the Executive Office
for United States Trustees, as may be issued from time to time.

4.

It will make all records relating to the Agency’s compliance with 11 U.S.C. § 111 available to the
United States Trustee upon request and cooperate with the United States Trustee for any scheduled or
unscheduled on-site visits and customer service audits.

5.

It will cooperate with the United States Trustee and the Executive Office for United States Trustees
and timely respond to any questions or inquiries concerning the Agency’s operations and services.

6.

No member of the board of directors or trustees, officer, manager, employee, counselor, or agent is a
United States Trustee Program employee, a panel or standing trustee, a federal judge, a federal court
employee, a certified public accountant that performs audits of the Agency’s trust account, or a
person with a financial or familial connection to the United States Trustee Program.

7.

No Agency owner, employee, officer, insider or related party, or member of the board of trustees,
directors, or any other corporate governing body will receive any commissions, incentives, bonuses,
or benefits (monetary or non-monetary) of any kind based on the outcome of a counseling session.

8.

It will provide adequate credit counseling services, including an outline of available counseling
opportunities and an analysis of the client’s budget, current financial condition, and factors that
caused such financial condition. Based on the analysis of the client’s financial condition, it will assist
the client in developing a plan to respond to the problems without incurring negative amortization of
debt.

9.

It will provide counselors who have adequate experience and training to provide credit counseling
services and who receive no commissions, incentives, bonuses, or benefits (monetary or nonmonetary) based on the outcome of a counseling session.

10.

Any fee, contribution, or payment received for counseling services will be reasonable in amount, and
the Agency will provide services without regard to a client’s ability to pay.

11.

It will not exclude any creditor from a debt management plan because the creditor declines to make a
“fair share” contribution to the Agency.

12.

It will not disclose or provide to a credit reporting agency information concerning whether an
individual debtor has received credit counseling or sought instruction concerning personal financial
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(April 2006)

management from the Agency, nor will it sell information about the client to any third party without
the client’s permission, regardless of whether the counseling is presented in a classroom, on the
telephone, or on the Internet.
13.

Any forms, agreements, contracts or other materials provided to a client will not limit the client’s
right to seek damages against a nonprofit budget and credit counseling agency as provided for in 11
U.S.C. § 111(g)(2).

14.

It will not pay or receive referral fees or other consideration for the referral of clients to or by the
Agency.

15.

It will refer clients for counseling services only to agencies that are approved by the United States
Trustee.

16.

It will conduct a state and federal criminal background check at least every five years for each person
providing credit counseling services, if such criminal background check is authorized under state law,
and shall not employ as a counselor anyone who has been convicted of any felony or a crime
involving fraud, dishonesty, or false statements, unless the United States Trustee determines, upon
review and in his or her discretion, circumstances warrant a waiver of this employment requirement.
The state criminal background check shall be conducted in the state where the counselor resides. If a
criminal background check is not authorized by state law, it will obtain a sworn statement from each
counselor, at least every five years, which attests to whether the counselor has been convicted of any
felony or a crime involving fraud, dishonesty, or false statements.

17.

If administering debt management plans, it has adequate financial resources to provide continuing
support services for debt management plans over the life of any plan, and it maintains client trust
accounts that are audited annually in accordance with generally accepted auditing standards by an
independent certified public accountant.

18.

If the Agency has contracted with another entity (“service provider”) to administer any part of its debt
management plan, the service provider is approved by the United States Trustee as a nonprofit budget
and credit counseling agency; or 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 the service provider agrees in writing 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.

19.

An approved Agency may state that it is approved to issue credit counseling services in compliance
with the Bankruptcy Code. However, any advertisement that refers to such approval shall only be
phrased in the following manner: “Approved to issue certificates in compliance with the Bankruptcy
Code. Approval does not endorse or assure the quality of an Agency’s services.” An approved
Agency will not use the United States Department of Justice’s seal, the United States Trustee’s seal,
the Bankruptcy Court’s seal, or any seal of the United States or a likeness thereof.

20.

It consents to the release and disclosure of the Agency’s name on the approved list and the
publication of the Agency’s contact information.

I HEREBY DECLARE under penalty of perjury that the foregoing 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

(April 2006)
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