Form xxxx Dedtor Education Application

OMB No. 1105-0085 Approval Expires 06/01/2009

U.S. Department of Justice
Executive Office for United States Trustees

APPLICATION FOR APPROVAL AS A PROVIDER OF A
PERSONAL FINANCIAL MANAGEMENT INSTRUCTIONAL COURSE
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 Provider, the federal tax identification number, and the question
number indicated on the top, right-side of the page.
Section 1. General Information Concerning the Provider
1.1

Name of Provider:_______________________________________________________________

1.2

Federal Tax Identification or Social Security Number of Provider:_____________________

1.3

United States Trustee assigned Provider Number (if previously approved):__________________

1.4

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

1.5

Primary business address:
Mailing address: (if different)

Street address:

1.6

Telephone No.: _______________________

Fax No.: _______________________________

Website: ____________________________
1.7

Principal contact for the Provider:
Name: ______________________________
Title:________________________________
Email address: _______________________________________________________________
If different then above:
Telephone No.:_____________________
Fax No.:_____________________________
Mailing address:

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(April 2006)

1.8

Provider is a(n):

_____ Individual
_____ Institute of Higher Education
_____ Corporation
_____ Limited Liability Corp.
_____ Partnership
_____ Limited Liability Partnership
_____ 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: Teaching Methods and Business Locations.

Section 2. Qualifications/Experience of Provider
2.1

How long has the Provider been in business?

2.2

How long has the Provider conducted personal financial management instructional courses?
______Years _____Months

2.3

Disclose the total number of students taught by the Provider within the last 12-month period.

2.4

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

2.5

Identify all owners within the last three years. Provide their name, street address, principal
occupation, current employer, and state whether they have been convicted of a felony or a crime
involving fraud, dishonesty, or false statements. Attach a Curriculum Vitae for each owner who
has been an owner for less than one year.

2.6

Identify all officers who served within the last three years. Provide their name, office title and
state whether they have been convicted of a felony or a crime involving fraud, dishonesty, or
false statements. Attach a Curriculum Vitae for each officer who has served for less than one
year. If no longer serving, state the date of termination.

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_____Years

_____Months

(April 2006)

2.7

Identify all directors/trustees who served within the last three years. Provide their name, street
address, principal occupation, current employer, and state whether they have 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 for less than one year. If no longer serving, state the date of
termination.

2.8

Identify each individual or entity who regularly refers debtor students to the Provider. State each
individual’s or entity’s street address, mailing address, telephone number and fax number, email
address, and Internet website, if any. Attach any contracts or agreements that are currently in
effect.

2.9

Provide the names of all individuals or entities with which the Provider 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 Provider 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 in effect during the last two years.

2.10

Disclose any accreditation(s) or certification(s) by accrediting or certifying organization(s).

2.11

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

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(April 2006)

2.12

List each state in which the Provider 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.

2.13

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 Provider or any
owner, officer, director, trustee, employee, or agent of the Provider is a party, pending or
adjudicated, within the last three years, and the outcomes.

2.14

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

2.15

List all other services that the Provider offers.

2.16

For the last two years, list all individuals or entities that the Provider refers debtor students 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 in effect.

2.17

Attach a copy of most recent year-end financial statement and federal income tax return.

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(April 2006)

Section 3. Experienced and Trained Personnel (Teachers)
3.1

Complete and attach Appendix D: Matrix of Current Teachers for each location that will be
staffed by teachers providing courses to debtor students. Enter the teacher’s name in the
employee box and complete the information as instructed.

3.2

Attach copies of any written standards, manuals, procedures, or guidelines provided to teachers of
the Provider’s course.

3.3

State the Provider’s policy for offering continuing education programs for its teaching staff.

3.4

Identify the individual who will serve as the supervisor/teacher who is qualified pursuant to
Section 3.2 of instructions and provide a Curriculum Vitae which describes the
supervisor’s/teacher’s experience and educational background.

Section 4. Learning Materials and Methodologies (Course Curriculum)
4.1

State the estimated length of the course in hours.
Classroom:

Telephone:

Internet:

4.2

Describe the procedure that will be employed to ensure the completion and submission of course
evaluation forms by debtor students and attach a copy of the proposed evaluation form.

4.3

If providing the instructional course via telephone or Internet, describe the Provider’s experience
and proficiency in providing courses in this manner.

Internet:

Telephone:

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(April 2006)

4.4

If providing the instructional course via telephone or Internet, describe how the course is
presented (e.g., course material is mailed to debtor students with follow up and testing performed
via telephone). Explain separately the course procedures for spouses who receive joint
instruction.
Telephone:

4.5

Internet:

If providing the instructional course via telephone or Internet, describe how the Provider verifies
the identity of the person taking the course, including verification procedures for spouses
receiving joint instructions.
Internet:

Telephone:

4.6

If providing the instructional course via telephone or Internet, describe how the Provider verifies
that the debtor students completed the course as it was designed and received a minimum of 2
hours of instruction, including verification procedures for spouses receiving joint instructions.
Internet:

Telephone:

4.7

If providing the instructional course via telephone or Internet, describe the procedures used if the
debtor student does not successfully complete the post course verification or does not receive the
minimum hours of instruction.
Telephone:

4.8

Internet:

Attach copies of the course materials used for planning purposes and instructional materials that
will be regularly provided to debtor students whether the course is taught in a classroom, by
telephone, or over the Internet.

Section 5. Facilities
5.1

Compete and attach Appendix E, Provider Checklist for Adequacy of Facilities, for each
classroom location.

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(April 2006)

Section 6. Fees and Issuance of Certificates
6.1

Attach copies of the following to the application:
•

Fee schedule or suggested contribution schedule for all fees and contributions to be paid by
debtor students, including any fees charged for telephone service, Internet service, materials,
or other items. If fees vary by judicial district or location, include a schedule for each place
where there is a variation.

•

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

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

Complete and attach Appendix F: Activity Report for Approved Providers.

Section 8. Acknowledgments, Agreements, and Declarations
8.1

Complete and attach an originally executed Appendix A: Acknowledgments, Agreements, and
Declarations in Support of Application for Approval as a Provider of a Personal Financial
Management Instructional Course.

8.2

Attach copies of the disclosure forms that will be provided to debtor students.

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 entity; 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 Owner, President, Chairman, Trustee, or
Other Authorized Official

Type or Print Name of Signer

______________________________________

_______________________________________

Type or Print Title of Signer (if applicable)

Date

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(April 2006)