Appendix E: Activity Report for Approved Providers

Application for Debt Education Course Provider

DE Appendix E

Application for Debt Education Course Provider

OMB: 1105-0085

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Appendix E: Activity Report for Approved Providers

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



Questions? Contact Executive Office for United States Trustees at (202) 514-4100, or [email protected].


Reporting Period: (Check one) July-December January-June Year: ____________


Provider No:


Name of Provider: E-Mail:


Shape1 Contact Person:

Someone who could answer USTP questions



Instructions: Please provide actual (not estimated) data for all debtors instructed by the Provider this reporting period. No cell should be left blank. If none, enter “0” in the cell.


Debtors Receiving Instruction this Reporting Period

Shape2

Q1 Number of debtors receiving instruction this reporting period

Shape3

Q2 Number of debtors requesting instruction in language other than English*


Shape4

Q3 Number of debtors provided instruction in language other than English*


Shape5

Q4 Number of hearing-impaired debtors requesting instruction



Shape6 Q5 Number of hearing-impaired debtors provided instruction


* Specify languages on next page


Instructions: Please provide actual (not estimated) data for all fees and bankruptcy certificates issued by the Provider this reporting period. No cell should be left blank. If none, please enter "0" in the cell.


Debtor Education Certificates Issued this Reporting Period



Instructional Method


Q9



a

In-Person

b

Telephone

c

Internet


Total Fees or

Q6 Certificates issued at no cost






Contributions

Q7 Certificates issued at reduced cost





a


Q8 Certificates issued at regular cost





b


Total





(Q6a+Q7a+Q8a) (Q6b+Q7b+Q8b) (Q6c+Q7c+Q8c) (Q9a+Q9b)











Course Evaluation Summary:



For courses conducted during

In-Person


Telephone


Internet


Probationary or Annual Period

%Yes

%No


%Yes

%No


%Yes

%No


COURSE










Goals were explained clearly.










Course topics were relevant to my life.










Learning materials were helpful.










Course content was easy to understand.










INSTRUCTOR










Instructor was well prepared.










Instructor was helpful.










COURSE ENVIRONMENT










Training facility was comfortable.










Facility location was convenient.










COURSE RESULTS










I learned something I can use.










I will use a budget at home.










Languages Requested other than English*


1. 6.


2. 7.


3. 8.


4. 9.


5. 10.



* If more than ten, please attach a list of additional languages requested.



Languages Provided other than English*


1. 6.


2. 7.


3. 8.


4. 9.


5. 10.



* If more than ten, please attach a list of additional languages provided.


File Typeapplication/vnd.openxmlformats-officedocument.wordprocessingml.document
File TitleAppendix F: Activity Report for Approved Providers
SubjectAppendix F: Activity Report for Approved Providers
AuthorUnited States Department of Justice
File Modified0000-00-00
File Created2022-05-05

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