Form xxxx DE Application Appendix A

Appendix A: Acknowledgments, Agreements, and Declarations

in Support of Application for Approval as a Provider
of a Personal Financial Management Instructional Course
(Application for Approval as a Provider of a Personal Financial Management Instructional Course)

Name of Provider:

The Provider 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 Provider also specifically assures, certifies, and agrees that:
1.

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

2.

No member of the board of directors or trustees, owner, officer, manager, employee, or
agent is a United States Trustee Program employee, panel trustee, or person with a
financial or familial connection to a panel trustee or an employee of the United States
Trustee Program. For purposes of this paragraph, a person is not deemed to have a
financial relationship to a panel trustee solely because the person is an employee of the
panel trustee.

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 related to the Provider’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 visit or customer service audit.

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
Provider’s operations and services.

6.

Its personnel will have adequate experience and training to provide effective instruction
and services.

7.

Its learning materials and methodologies are designed to assist debtors in understanding
personal financial management and are consistent with stated objectives of such
instructional course.

8.

Any fee, contribution, or payment received for education services will be reasonable in
amount, and the Provider will provide services without regard to a debtor student’s
ability to pay.
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(April 2006)

9.

It will not pay or receive referral fees or other consideration for the referral of debtor
students.

10.

Any forms, agreements, contracts or other materials furnished to a debtor student will not
limit the debtor student’s ability to bring an action or claim under the provision of the
United States Bankruptcy Code, 11 U.S.C. § 101 et seq.

11.

The course will not contain any commercial advertising, and the Provider shall not
promote, market, or sell financial products; solicit business of any type; or sell
information about the debtor to any third party without the debtor’s permission, whether
the course is presented in a classroom, on the telephone, or on the Internet.

12.

An approved Provider may state that it is approved to provide an instructional course in
personal financial management as required under the Bankruptcy Code. However, any
advertisement that refers to such approval shall only be phrased in the following manner:
“Approved to issue certificates evidencing completion of a personal financial
management instructional course in compliance with the Bankruptcy Code. Approval
does not endorse or assure the quality of a Provider’s services.” Approved Providers
shall 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.

13.

It consents to the release and disclosure of the Provider’s name on the approved list and
the publication of the Provider’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 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)