OMB Number 1105-00 Credit Counseling Application

OMB No. 1105-0084 Approval Expires ______

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.

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 agency’s answer to that question is identical to its answer in the most recent application, the agency may check the box indicating “no change” and continue to the next question. Where no box appears, the agency must answer the question, even if its response has not changed since the previous application.

Section 1. General Information Concerning the Agency

1. Check only one box.

G New Applicant. Continue to question 1.2.

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

2. Name of Agency: _________________________

3. Federal Tax Identification Number of Agency:_____________________

1.4 United States Trustee assigned Agency 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 Agency:

Name: Title:_______________________________

Email address:

If different than above:

Telephone No.:_____________________ Fax No.:_____________________________

Mailing address:

1.9 Agency is a(n): _____ Corporation _____ Institute of Higher Education

_____ Partnership _____ Limited Liability Partnership

_____ Limited Liability Corp. _____ 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: Counseling Methods and Business Locations, listing each location that will be staffed by counselors providing credit counseling services to clients.

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. Status as a Nonprofit Organization

2.1 NC G 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 NC G 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 NC G 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.

2.5 NC G 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 NC G 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.

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

3.1 How long has the Agency been in business? _____Years _____Months

3.2 How long has the Agency provided credit counseling services? _____Years _____Months

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 NC G Disclose any memberships with credit counseling associations.

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

3.7 NC G 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 NC G 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.

3.9 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 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 NC G 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:

1. the Curriculum Vitae of each supervisor describing the supervisor’s experience and educational background;

2. a business plan; and

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

4.2 NC G 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 NC G 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.

5. Attach original or copies of the following to the application:

New Applicants: Complete each applicable section. Supply information responsive to each category listed below on a separate attachment. Applicants who seek approval to provide more than one delivery method shall provide a complete response for each delivery method.

NC G Returning Applicants: If the agency has made no changes to its counseling methods or procedures since the previous application, as approved, check “NC” and proceed to Section 5.

1. 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.

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

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

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

5. 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.

Section 5. Qualifications of Counselors

5.1 New applicants: 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.

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 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 NC G 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 NC G 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 NC G 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):

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

7. 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.)

8. Proof of adequate employee bonding or fidelity insurance.

9. 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 New applicants: Do not complete Appendix E: Activity Report for Approved Agencies.

Returning applicants: 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 NC G 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