OMB Number 1105-00 Debt Education Application

OMB No. 1105-0085 Approval Expires 08/31/2012

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.

Do not leave any questions blank. If the applicant has no relevant information to provide, state “N/A.” Please see instructions for detailed guidance on completing the questions in each section.

New Applicants. Check the box marked “New Applicant” in question 1.1. Answer every question in the application. Do not check any of the “No Change” boxes. Where a question provides alternatives for new applicants and returning applicants, respond as directed for new applicants only.

Returning Applicants. Check the box marked “Returning Applicant” in question 1.1. Where a question provides alternatives for new applicants and returning applicants, respond as directed for returning applicants only. Except where a “No Change” box appears, complete all questions in the application, even if the requested information has not changed since the most recent application.

Statement of No Change for Returning Applicants. Where a “No Change” box appears beside a question (marked by a box and the letters “NC”), if the Provider’s answer to that question is identical to its answer in the most recent application, the Provider may check the box indicating “no change” and continue to the next question. Where no box appears, the Provider must answer the question, even if its response has not changed since the previous application.

Section 1. General Information Concerning the Provider

1. Check only one box.

G New Applicant. Continue to question 1.2.

G Returning applicant. Check here and provide United States Trustee assigned Provider number:__________________

2. Name of Provider:

3. Federal Tax Identification or Social Security Number of Provider:_____________________

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

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

1.6 Primary business address:

Street address:

Mailing address: (if different)

1.7 Telephone No.: _______________________ Fax No.: _______________________________

Website: ____________________________

1.8 Principal contact for the Provider:

Name: Title:________________________________

Email address:

If different than above:

Telephone No.:_____________________ Fax No.:______________________________

Mailing address:

1.9 Provider is a(n): _____ Individual _____ Institute of Higher Education

_____ Corporation _____ Limited Liability Corp.

_____ Partnership _____ Limited Liability Partnership

_____ Other ____________________________________________

1.10 State of organization: __________________ Date of organization: _____________________

1.11 New applicants: Complete and attach Appendix B: Judicial Districts, listing each judicial district in which approval is sought, and Appendix C: Teaching Methods and Business Locations, listing each location that will be staffed by teachers providing instruction to debtor students.

Returning applicants: If the applicant has no changes to Appendices B and/or C from the previous application as approved, check the appropriate NC box or boxes and do not submit the appendix or appendices. Otherwise, complete Appendices B and/or C and submit with the completed application.

NC G Appendix B

NC G Appendix C

Section 2. Qualifications/Experience of Provider

2.1 How long has the Provider been in business? _____Years _____Months

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 NC G 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 NC G 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 NC G 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.

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

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

2.12 NC G 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 NC G 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 NC G 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 NC G 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.

Section 3. Experienced and Trained Personnel (Teachers)

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

NC G Returning applicants: If the applicant has no changes to Appendix D from the previous application as approved, check the NC box and do not submit Appendix D. Otherwise, complete Appendix D and submit with the completed application.

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

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

3.4 NC G 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 NC G State the estimated length of the course in hours.

Classroom:

Telephone:

Internet:

4.2 NC G 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.

Instructions for sections 4.3 through 4.7.

For New Applicants: Complete each applicable question. Supply responses on a separate attachment. Applicants who seek approval to provide more than one delivery method shall provide a complete response for each delivery method.

For Returning Applicants: If the Provider has made no changes to its instructional methods or procedures since the previous application, as approved, check “NC” for each relevant section and proceed to section 5.

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

Telephone:

Internet:

4.4 NC G 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:

Internet:

4.5 NC G 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.

Telephone:

Internet:

4.6 NC G 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.

Telephone:

Internet:

4.7 NC G 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:

Internet:

4.8 NC G 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 New applicants: Complete and attach Appendix E: Provider Checklist for Adequacy of Facilities, for each classroom location listed on Appendix C.

NC G Returning applicants: If the applicant has no classroom location changes to Appendix C, and has no changes to Appendix E from the previous application as approved, check the NC box and do not submit Appendix E. Otherwise, complete Appendix E with respect to any new classroom locations or changes to existing locations, and submit with the completed application.

Section 6. Fees and Issuance of Certificates

6.1 Attach copies of the following to the application:

1. NC G 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.

2. NC G 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 New applicants: Do not complete Appendix F: Activity Report for Approved Providers.

Returning applicants: 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 NC G 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 Type or Print Name of Signer

Other Authorized Official

______________________________________ _______________________________________

Type or Print Title of Signer (if applicable) Date

(December 2011)

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