Revision 10.16.201 APPLICATION FOR APPROVAL AS A NONPROFIT BUDGET AND CREDI

OMB No. 1105-0084 Approval Expires

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

INSTRUCTIONS FOR APPLICATION FOR APPROVAL AS A
NONPROFIT BUDGET AND CREDIT COUNSELING AGENCY
Introduction. In accordance with 11 U.S.C. § 111, as implemented by Application
Procedures and Criteria for Approval of Nonprofit Budget and Credit Counseling
Agencies by United States Trustees, 28 C.F.R. §§ 58.12 - 58.24 (the “Rule”), a nonprofit
budget and credit counseling agency (the “Agency”) seeking approval by the United States
Trustee 1 shall submit an application to the Executive Office for United States Trustees
(“EOUST”) in the form described below. The Agency shall provide all information and
documents required by the EOUST or the United States Trustee responsible for each
judicial district in which the Agency seeks approval. Unless otherwise stated, the
application and appendices shall be typewritten2 using the space provided on the form, as
well as attachments if necessary.
The application has been revised to reflect changes to the process under the Rule. All
Agencies should review the Rule thoroughly before completing an application.
Application Form and Instructions. The application form and Instructions comprise the
following sections:

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Section 1.

General Information Concerning the Agency

Section 2.

Status as a Nonprofit Organization

Section 3.

Quality, Experience, and Background in Providing Credit
Counseling Services

Section 4.

Credit Counseling Methods and Curriculum

As defined in 28 C.F.R. § 58.12(b)(39), the term “United States Trustee” means, alternatively:
(i) The Executive Office for United States Trustees;
(ii) A United States Trustee appointed under 28 U.S.C. § 581;
(iii) A person acting as a United States Trustee;
(iv) An employee of a United States Trustee; or
(v) Any other entity authorized by the Attorney General to act on behalf of the United States under this
part.

“Typewritten” includes completion of the online fillable PDF form, or completion of the form using a word
processing application or a typewriter.
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Section 5.

Fees and Fee Waivers

Section 6.

Disclosures

Section 7.

Administration of Debt Repayment Plans and the Safekeeping
and Payment of Client Funds

Section 8.

Appendices
Appendix A. Acknowledgments, Agreements, and Declarations in
Support of Application for Approval as a Nonprofit Budget
and Credit Counseling Agency
Appendix B. Judicial Districts
Appendix C. Business Locations
Appendix D. Matrix of Current Counselors
Appendix E. Activity Report for Approved Credit Counseling Agencies

Section 9.

Certification and Signature

Except where a “No Change” (“NC”) box appears, complete all items in the application, even
if the requested information has not changed since the most recent application. Do not leave
any items blank. If the Agency has no information to provide, state “N/A” with respect to the
relevant item.
New Applicants. Check the box marked “New Applicant” in item 1.1. Complete every item
in the application and submit completed Appendices A through E. Do not check any of the
“NC” boxes. Where an item provides alternatives for new applicants and returning applicants,
respond as directed for new applicants only.
Returning Applicants. Check the box marked “Returning Applicant” in item 1.1. Where an
item provides alternatives for new applicants and returning applicants, respond as directed
for returning applicants only.
Statement of No Change for Returning Applicants. Where a “NC” box appears beside an
item, if the Agency’s response to that item is identical to its response in the most recent
application, the Agency may check the “NC” box indicating no changes have occurred and
continue to the next item. If an item does not offer the option of checking a “NC” box, then
the Agency must complete the item even if its response has not changed since the previous
application.
Mailing Instructions, Information Requests, and Notifications. The application should be
completed in its entirety, which includes all supplemental documents and information that are
requested, before submission to the United States Trustee. An incomplete application may
result in delay or denial of the application. Once completed, the application should be sent by
one of two permissible delivery methods:
(1)

By electronic mail to the following

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address: [email protected]
The application may be submitted in one or more e-mail transmissions to accommodate file
size limitations. The maximum size of any e-mail is 10MB. Please include the Agency’s name
(and Agency number, if previously assigned), in the subject line of all e-mail transmissions.
Retain the original application for your records.
(2)

By overnight mail to the following address:
Executive Office for United States Trustees
Credit Counseling Application Processing
441 G Street, N.W.
Suite 6150
Washington, D.C. 20530
(202) 514-4100

As soon after receipt as practicable, the United States Trustee will send the Agency an
acknowledgment letter confirming receipt. The principal contact identified in the application
shall receive all notices and requests for information. Correspondence with the United
States Trustee should be submitted to the address set forth above, unless otherwise
instructed.
Duty to Notify the United States Trustee. The Agency has a continuing duty to promptly
notify the United States Trustee of any circumstances that would materially alter or change a
response to any section of the application regardless of whether they occur while an
application to become an approved Agency is pending before the United States Trustee or
after the Agency has been approved. Notification to the United States Trustee must be in
writing, signed by an authorized official, and include all pages of the application and/or
appendices that are affected by the change. Notification shall be transmitted in the same
manner as the application.
The Agency shall immediately notify the United States Trustee in writing of any failure by the
Agency to comply with any statutory or regulatory standard or requirement specified in 11
U.S.C. §§ 109 or 111, the Rule, or the terms under which the United States Trustee approved
the Agency to act as an approved Agency. Specifically, the Agency shall immediately notify
the United States Trustee, in writing, of any of the following events:
(1) Notification by the Internal Revenue Service or by a state or local taxing authority
that the approved Agency has been selected for audit or examination regarding its taxexempt status, or any notification of a compliance check by the Internal Revenue
Service or by a state or local taxing authority;
(2) Revocation or termination of the approved Agency’s tax-exempt status by
any governmental unit or by any judicial officer;
(3) Cessation of business by the approved Agency or by any office of the Agency, or

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withdrawal from any federal judicial district(s) where the approved Agency is
approved;
(4) Any investigation of, or any administrative or judicial action brought against,
the approved Agency by any governmental unit;
(5) Termination or cancellation of any surety bond or fidelity insurance;
(6) Any administrative or judicial action brought by any entity that seeks recovery
against a surety bond or fidelity insurance;
(7) Any action by a governmental unit or a court to suspend or revoke the approved
Agency’s articles of incorporation, or any license held by the approved Agency, or
any authorization necessary to engage in business;
(8) A suspension, or action to suspend, any accreditation held by the approved Agency,
or any withdrawal by the approved Agency of any application for accreditation, or any
denial of any application of the approved Agency for accreditation;
(9) A change in the approved Agency’s nonprofit status under any applicable law; or
(10) Any change in the banks or financial institutions used by the Agency.
Approval Period and Deadline for Submission of Application for Renewal. Unless
terminated earlier, the Agency approved to provide credit counseling services for the first
time shall be approved for a six-month probationary period. Except as provided below, each
approval period after the probationary period shall be for one year. The Agency shall apply
no later than 45 days before the expiration of its existing approval period to be considered for
renewal. The Agency is responsible for monitoring the expiration date of the current approval
period as well as the application deadline, and for timely submitting an application. The
United States Trustee will not send application deadline reminders to the Agency.
So long as the Agency has submitted a complete and timely application for renewal, it may
continue to provide credit counseling services while its application for renewal is under
review by the United States Trustee. If the renewal application is approved for an additional
one-year period, that renewal period will begin on (a) the date after its current approval period
expires, or (b) the date the United States Trustee approves the application, whichever is later.
If the Agency does not submit an application for renewal before the expiration of its current
approval period, the approval will automatically expire, the Agency no longer will be
authorized to act as an approved Agency, and the Agency must apply for a new six-month
probationary period before providing credit counseling services to clients pursuant to 11
U.S.C. §§ 109 and 111.
Amendments. After approval, the Agency must obtain the United States Trustee’s approval
before making any of the following changes:

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(1) Cancellation or change in the amount of the surety bond or employee fidelity
bond or insurance;
(2) The engagement of an independent contractor to provide credit counseling
services or to have access to, possession of, or control over client funds;
(3) Any increase in the fees, contributions, or payments received from clients
for credit counseling services or a change in the Agency’s fee policy;
(4) Expansion into additional federal judicial districts;
(5) Any changes to the method of delivery the approved Agency employs to
provide credit counseling services; or
(6) Any changes in the approved Agency’s credit counseling services.
The Agency shall submit an amended application, reflecting all material changes that will
occur due to the changes, and include a newly executed Section 9, “Certification and
Signature.” The amended application need only include the items affected by the changes.
Burden Statement. Respondents are not required to complete this form unless it contains a
valid OMB number. The public reporting burden for this application is estimated to average
ten hours for an initial application and four hours for a re-application, including time for
reviewing instructions, gathering information, and completing the application. Comments
regarding this burden estimate or any other aspect of this application, including suggestions for
reducing the burden, should be directed to the Executive Office for United States Trustees,
Credit Counseling Application Processing, 441 G Street, N.W., Suite 6150, Washington, D.C.
20530.
Privacy Act Statement. Section 111 of title 11, United States Code, authorizes the collection
of this information. The primary use of this information is by the United States Trustee to
approve Agencies to provide services as nonprofit budget and credit counseling agencies.
Disclosure of this information may be to an appropriate federal, state, local, regulatory, tribal,
or foreign law enforcement agency when the information indicates a violation or potential
violation of law, or to a complainant or victim when such information is necessary to provide
an explanation concerning the results of an investigation of which they complained or were a
victim. Other disclosures may be made pursuant to the routine uses enunciated in the United
States Trustee Program’s system of records notice, UST-005, “Credit Counseling and Debtor
Education Files and Associated Records.” See 71 Fed. Reg. 59,818, 59,727-59,830 (Oct. 11,
2006). Additional disclosure of the information may be to district and regional offices of each
United States Trustee. The information will not be shared with any other agencies unless
allowed by law.
Any person doing business with the federal government must furnish a taxpayer identifying
number. 31 U.S.C. § 7701. Furnishing the taxpayer identifying number, as well as other data,

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is voluntary, but failure to do so may delay or prevent action on the application.
APPLICATION AND INSTRUCTIONS
Section 1.

General Information Concerning the Agency

Item 1.1: United States Trustee assigned Agency number. New applicants: Enter “N/A” for
this item. Returning applicants: Provide the four or five digit number the United States
Trustee assigned when the Agency first applied to be an approved Agency.
Item 1.2: Name of Agency. Provide the Agency’s legal name as designated by the state
of incorporation or organization.
Item 1.4: Additional names. List all aliases, d/b/a, or fictitious names the Agency currently
uses (the Agency should list former names in item 2.2).
Section 2.

Status as a Nonprofit Organization

Guidelines.

Organization and operation as a nonprofit entity. The Agency must be
organized and operated as a nonprofit entity and have a board of directors, the
majority of which: (a) are not relatives; (b) are not employed by the Agency;
and (c) will not directly or indirectly benefit financially from the outcome of
the counseling services provided by the Agency. The Agency should avoid
any conduct or transactions that generate a private benefit for any individual
or group related or connected to the Agency.
Ethical standards. The Agency shall not engage in any conduct or transaction,
other than counseling services, that generates a direct or indirect financial
benefit for any member of the board of directors or trustees, officer,
supervisor, or any relative thereof. In addition, no such person shall receive
any commissions, incentives, bonuses, or benefits (monetary or non-monetary)
of any kind that are directly or indirectly based on the financial or legal
decisions any client makes after requesting credit counseling services.
The Agency may not enter into any referral agreements or receive any
financial benefit that involves the Agency paying to or receiving from any
entity or person referral fees for the referral of clients to or by the Agency,
except payments under a fair share agreement. The Agency may not enter into
agreements involving counseling services that create a conflict of interest.
The Agency may not provide counseling services to a client with whom it has
a lender-borrower relationship.
No member of the board of directors or trustees, officer or supervisor of an
approved Agency may be: a relative of an employee of the United States
Trustee; a trustee appointed under 28 U.S.C. §§ 586(a)(1) or (b) for any federal
judicial district where the Agency is providing or is applying to provide

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counseling services; a federal judge in any federal judicial district where the
Agency is providing or is applying to provide counseling services; a federal
court employee in any federal judicial district where the Agency is providing
or is applying to provide counseling services; or a certified public accountant
that audits the Agency’s trust account.
Specific Instructions.
Item 2.1: Basis for nonprofit status. Describe the Agency’s nonprofit purpose, such as its
public, charitable, educational, or other organizing purpose under applicable state law. If the
Agency is tax-exempt pursuant to section 501(c)(3) or another section of the Internal
Revenue Code, please identify the tax-exempt status and applicable Internal Revenue Code
section.
Items 2.4 and 2.8: Current officers, directors, and trustees. Provide information about
individuals currently serving as officers, directors, and trustees. “Compensation” includes
both direct compensation, such as wages and salaries, and indirect compensation, such as
bonuses, deferred compensation, and noncash compensation.
Item 2.5: Material management changes. New applicants: State whether the Agency’s
officers or the members of its board of directors/trustees have changed in the last three years.
If so, complete items 2.6 and/or 2.7. If not, continue to item 2.8. Returning applicants: State
whether the Agency’s officers or the members of its board of directors/trustees have changed
since the most recent application. If so, complete items 2.6 and/or 2.7. If not, continue to item
2.8.
Items 2.6 and 2.7: Former officers, directors, and trustees. New applicants: Provide
information about individuals who are not currently on the board, but have served as officers,
directors, or trustees within the last three years. Returning applicants: Provide information
about individuals who are not currently on the board, but have served as officers, directors, or
trustees within the last year.
When supplying address information, provide the individual’s current employer or residential
address, and not the Agency’s business address. “Compensation” includes both direct
compensation, such as wages and salaries, and indirect compensation, such as bonuses,
deferred compensation, and noncash compensation.
Item 2.9(a) and (b): Referrals. Provide information about individuals or entities who provide
referrals to the Agency or receive referrals from the Agency. Disclose oral referral
agreements and arrangements as well as written agreements.
Item 2.9(c): Contracts. Disclose all contracts with related individuals or entities, whether or
not they pertain to credit counseling services. For purposes of this item, a “related entity”
includes a business in which an officer, director or employee of the Agency, 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.

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Item 2.10: Independent contractors. The term “independent contractor” means a person or
entity who provides any goods or services to the Agency other than as an employee and as to
whom the Agency does not:
(1) direct or control the means or methods of delivery of the goods or services
being provided;
(2) make financial decisions concerning the business aspects of the goods or
services being provided; and
(3) have any common employees.
“Independent contractors” do not include counselors employed by the Agency. Do not list
the Agency’s own counselors; list those on Appendix D. If the Agency lists independent
contractors with access to, possession of, or control over client funds, complete Section 7 of
this Application.
Section 3. Quality, Experience, and Background in Providing Credit Counseling
Services
Guidelines.

Generally. The Agency shall operate in a prudent business manner and shall
deal responsibly and effectively with matters relating to the quality,
effectiveness, and financial security of the services it provides.
Business experience. The Agency must have adequate experience and
background in credit counseling. To meet this requirement, the Agency must
have provided credit counseling services for the last two years. If the Agency
has not provided credit counseling services for the last two years, then it must
employ in each office location that provides counseling services at least one
supervisor with experience and background in providing credit counseling for
no less than two of the last five years.
Compliance with laws and regulations. The Agency must be 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 Agency
conducts counseling services, including all laws governing licensing and
registration.

Specific Instructions.
Item 3.2: Time in business. State the length of time the Agency has offered credit counseling
services. The Agency with fewer than two years of experience immediately preceding the
application date shall complete item 3.3. All other Agencies may continue to item 3.4.
Item 3.6: Revocation of accreditation or certification. If the Agency’s accreditation was

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revoked, suspended, or lapsed at any time during the last five years, state the date(s) of
revocation, suspension or lapse, and provide a detailed explanation of the circumstances that
led to the Agency’s accreditation being revoked, suspended, or lapsed. If any counselor’s
certification was revoked, suspended, or lapsed at any time during the last five years, identify
the counselor, identify the relevant date(s) and provide a detailed explanation of the
circumstances.
Item 3.8: Financial statements. Provide audited financial statements. If an Agency has not
commenced operations as of the application date, it may provide pro forma financial
statements in lieu of audited financial statements.
Item 3.9: Litigation. List all legal actions, proceedings, investigations, arbitrations,
mediations, and potential bond or other claims, whether pending or adjudicated, in which the
Agency, any affiliate listed in the response to item 2.8(c), or any officer, director, trustee,
employee, or agent of the Agency is a party, and the outcomes of any such actions.
Items 3.10 and 3.11: Regulatory oversight, investigations, and Internal Revenue Service
matters. Disclose audits, investigations, and enforcement actions by state and local tax,
oversight, and regulatory agencies in the response to item 3.10. In the response to item 3.11,
provide the correspondence relating to Internal Revenue Service audits, investigations, and
enforcement actions, including: a letter indicating that the Agency’s credit counseling
activities are consistent or inconsistent with its tax-exempt status as of a certain date; a “nochange advisory;” a closing agreement; a notice of referral; or a revocation of the Agency’s
exemption. Routine audits performed on an annual or other periodic basis need not be
disclosed, except to the extent they form the basis of an enforcement action.
Item 3.12: Continuing obligation to update. Disclose to the United States Trustee any new
actions of the type described in items 3.6, 3.9 or 3.10 that commence during the application
review period. Provide to the United States Trustee copies of correspondence described in
item 3.11 sent or received by the Agency or an affiliate during the application review period.
Section 4.

Credit Counseling Methods and Curriculum

Guidelines.

Adequate credit counseling services. The Agency shall provide, at a minimum,
an adequate written analysis, particularized to the client, of each client’s current
financial condition, including a discussion of the factors that caused such
financial condition, budget analysis, consideration of all alternatives to resolve
a client’s credit problems, and formation of a plan to respond to the financial
problems without incurring negative amortization of debt. The typical length of
an adequate counseling session is 60 minutes.
In the case of internet counseling, counseling is not complete until the
client has engaged in interaction with a counselor, whether by electronic
mail, live chat, or telephone, following the automated portion of the
counseling session.

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Providers of telephone services or internet services. In addition to meeting all
other requirements, the Agency that provides telephone services or internet
services must demonstrate sufficient experience and proficiency in designing
and providing services by these methods of delivery, including proficiency in
employing verification procedures to ensure the person receiving the
counseling services is the client and to determine whether the client has
completely received counseling services. Determining whether the client has
completely received counseling services means ensuring that the client is the
same person who both commences and completes the counseling, and that the
client engages in interaction with a counselor by electronic mail, live chat, or
telephone following the automated portion of the counseling. Identity
verification requires the Agency to:
(a) obtain one or more unique personal identifiers from the client
and assign an individual access code, user ID, or password at the
time of enrollment; and
(b) require the client to provide the appropriate access code, user ID,
or password, and also one or more of the unique personal identifiers
during the course of delivery of the counseling services.
The Agency shall furnish toll-free telephone numbers for both hearing and
hearing-impaired clients and potential clients whenever telephone
communication is required. The Agency shall provide telephone amplification,
sign language services, or other communication methods for hearing-impaired
clients or potential clients.
Language services. The Agency shall inform clients with limited English
proficiency of the languages it offers.
Prohibition against legal advice. The Agency shall refrain from giving
legal advice to clients or potential clients.
Certificates of counseling. The Agency agrees to issue certificates of
counseling in accordance with the directives established by the United States
Trustee. For reference, please consult 28 C.F.R. § 58.22.
Specific Instructions.
Check the box for each method of delivery for which the Agency seeks approval, and
describe any languages, other than English, in which the Agency provides counseling. The
former method of delivery, “telephone/internet,” has been eliminated. The Agency must
select either telephone or internet based on the primary method used for delivery of
counseling services.
Item 4.2: Other counseling services. List the other types of counseling services the Agency
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provides, whether or not related to credit counseling, such as housing counseling, or mortgage
counseling.
Item 4.3: Language referrals. List the number of referrals of clients or potential clients the
Agency provided to other approved Agencies for counseling based on limited English
proficiency, and identify the languages, other than English, requested by such clients or
potential clients.
Items 4.4 - 4.6: Counseling process. The Agency that seeks approval to provide more than
one delivery method shall provide a complete response for each delivery method. As to each
element below, provide examples of counseling or identity verification forms (whether used
by the client, the counselor, or both), written counseling materials, procedures, manuals,
scripts, outlines, and/or guidelines, where applicable. If the listed materials are available on
the internet (whether or not accessible to the client), provide the URL for the website and, if
necessary, instructions for accessing such materials, such as a username and a password. If
the listed materials are available only on the Agency’s intranet, provide printed screens of all
such resource materials. The Agency shall not unilaterally change its counseling methods
or services without prior United States Trustee approval.
Item 4.4: In-person counseling. Describe the counseling process, beginning with the process
of providing information to or obtaining information from a client or potential client, and
ending with certificate issuance:
(a)

Describe the process of obtaining client information and providing mandatory
disclosures. If any portion of the information-gathering takes place by
telephone or internet, describe that portion in detail and provide the telephone
number a client calls or the URL for the website where the client provides the
information. Provide copies of any and all agreements and consents the Agency
requires clients to sign in connection with counseling services. If the agreement
or consent takes an electronic form, provide the URL for the website where the
client accesses the form;

(b)

Describe the substance of the counseling services, including an analysis of
the client’s current financial condition, factors that caused the client’s
financial condition, and how a client can develop a plan to respond to his or
her financial problems without incurring negative amortization of debt; and

(c)

Describe the certificate issuance process, including the timing of
certificate issuance and the Agency’s policies concerning which
personnel may issue certificates.

Item 4.5: Telephone counseling. Describe the counseling process, beginning with the process
of providing information to or obtaining information from a client or potential client, and
ending with certificate issuance:
(a)

Describe the process of obtaining client information and providing mandatory

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disclosures. To the extent information-gathering takes place by telephone or
internet, describe that portion in detail and provide the telephone number a
client calls or the URL for the website where the client provides the
information. Provide copies of any and all agreements and consents the Agency
requires clients to sign in connection with counseling services. If the
agreement or consent takes an electronic form, provide the URL for the website
where the client accesses the form;
(b)

Describe the substance of the counseling services, including an analysis of
the client’s current financial condition, factors that caused the client’s
financial condition, and how a client can develop a plan to respond to his or
her financial problems without incurring negative amortization of debt;

(c)

Describe the Agency’s experience and proficiency in providing
counseling services over the telephone;

(d)

Describe the Agency’s client identity verification processes, including the
method by which the Agency confirms the identity of the client before
receiving counseling services by telephone by:
(1)

obtaining one or more unique personal identifiers from the client and
assigning an individual access code, user ID, or password at the time of
enrollment; and

(2)

requiring the client to provide the appropriate access code, user ID, or
password, and also one or more of the unique identifiers during the
course of delivery of counseling services;

(e)

Describe the criteria by which the Agency determines that the client has
completed the counseling as it was designed. If the Agency provides
automated telephone counseling, describe the process by which the client
engages in interaction with a counselor, whether by electronic mail, live chat,
or telephone, following the automated portion of the counseling session;

(f)

Describe how and when the Agency delivers the written analysis of the client’s
current financial condition to the client;

(g)
(h)

Provide a complete response to items 4.5(d), (e), and (f) as to spouses
receiving joint counseling; and
Describe the certificate issuance process, including the timing of
certificate issuance, the method of delivery to the client, and the
Agency’s policies concerning which personnel may issue certificates.

Item 4.6: Internet counseling. Describe the counseling process, beginning with the process
of providing information to or obtaining information from a client or potential client, and

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ending with certificate issuance:
(a)

Describe the process of obtaining client information and providing mandatory
disclosures. To the extent information-gathering takes place by telephone or
internet, describe that portion in detail and provide the telephone number a
client calls or the URL for the website where the client provides the
information. Provide copies of any and all agreements and consents the Agency
requires clients to sign in connection with counseling services. If the agreement
or consent takes an electronic form, provide the URL for the website where the
client accesses the form;

(b)

Describe the substance of the counseling services, including an analysis of
the client’s current financial condition, factors that caused the client’s
financial condition, and how a client can develop a plan to respond to his or
her financial problems without incurring negative amortization of debt;

(c)

Describe the Agency’s experience and proficiency in providing
counseling services over the internet;

(d)

Describe the Agency’s client identity verification processes, including the
method by which the Agency confirms the identity of the client before
receiving counseling services by internet by:
(1) obtaining one or more unique personal identifiers from the client
and assigning an individual access code, user ID, or password at the
time of enrollment; and
(2) requiring the client to provide the appropriate access code, user ID,
or password, and also one or more of the unique personal identifiers
during the course of delivery of the counseling services;

(e)

Describe the criteria by which the Agency determines that the client has
completed the counseling as it was designed. Describe the process by which
the client engages in interaction with a counselor, whether by electronic mail,
live chat, or telephone, following the automated portion of the counseling
session;

(f)

Describe how and when the Agency delivers the written analysis of the client’s
current financial condition to the client;

(g)

Provide a complete response to items 4.5(d), (e), and (f) as to spouses
receiving joint counseling; and

(h)

Describe the certificate issuance process, including the timing of
certificate issuance, the method of delivery to the client, and the
Agency’s policies concerning which personnel may issue certificates.

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Section 5.

Fees and Fee Waivers.

Guidelines:

Fees. The Agency shall charge reasonable fees for, or relating to, credit
counseling services. A fee of less than or equal to $50 is presumed reasonable;
fees in excess of $50 are presumed not reasonable and require prior approval of
the United States Trustee. The Agency may exceed the presumptively
reasonable fee after receiving approval from the United States Trustee by
demonstrating, at a minimum, that its costs for delivering the counseling
services justify the requested fee. The Agency bears the burden of establishing
that its proposed fee is reasonable.
Fee waivers. The Agency must provide services without regard to a client’s
ability to pay the fee. A client is presumptively entitled to a fee waiver if the
client’s household current income is less than 150 percent of the poverty
guidelines updated periodically in the Federal Register by the U.S. Department
of Health and Human Services under the authority of 42 U.S.C. § 9902(2), as
adjusted from time to time, for a household or family of the size involved in the
fee determination. The Agency may rebut the presumption, and charge a
reduced fee, if the Agency determines, based on income information the client
submits in connection with counseling services, that the client is able to pay the
fee in a reduced amount.

Specific Instructions.
Item 5.1: Fees.
(a)

Types of fees. Disclose all fees charged for counseling services, including
additional fees for certificate issuance. If the Agency charges different fees
based on delivery method (e.g., in-person, telephone, and internet counseling),
disclose the different fees and specify the applicable delivery method.

(b)

Fee reductions and special rates. Do not include reductions based on inability
to pay in response to this item. Disclose such fee waivers and fee reductions in
the response to item 5.2(a). If the Agency charges a reduced rate for spouses
who take the course together, disclose the joint rate as well as the individual
rate. If the Agency charges reduced rates based on criteria other than ability to
pay, such as reduced rates to clients of certain attorneys or law firms, or clients
obtained through referrals, disclose the reduced rate and specify the basis for
the reduction and the identity of the individual or entity serving as the basis for
reduction. If the reduction is pursuant to oral or written agreement, or is in
consideration of a referral agreement or arrangement, disclose such agreements
or arrangements in response to item 2.8. The Agency shall not unilaterally
decrease its fee without prior United States Trustee approval.

(c)

Fee communication to clients; disclosures. State whether the disclosures are
communicated to clients and potential clients orally, by recording, in writing,

14

or electronically (for example, via the internet or e-mail). Specify the timing
of disclosures to clients and potential clients. Provide the URL for electronic
disclosures. Include copies of all written and/or electronic disclosures in
response to section 6; do not include copies of the disclosures here.
(d)

Fees exceeding $50 per client. If the Agency has been approved to charge a
fee over $50 per client in connection with a prior application, the Agency need
not provide a fee justification in connection with this application unless the
Agency seeks a further increase of its fees. If the Agency seeks an increase
over $50 per client for the first time, or seeks to increase an existing fee in
excess of $50 per client, the Agency shall provide appropriate documentation
demonstrating that its costs for providing the counseling services exceed the
proposed fee. The Agency shall not unilaterally increase its fee without
prior United States Trustee approval.

Item 5.2: Fee waiver and fee reduction.
(a)

Fee waiver policies. Fully describe any and all fee waiver and fee reduction
policies based on the client’s ability to pay, including those policies at the
discretion of the Agency or counselor, such as the client’s net worth,
dependence on government assistance, or receipt of pro bono legal services in
connection with a filed or anticipated bankruptcy case.

(b)

Fee waiver disclosure. State whether the fee waiver disclosures are
communicated to clients and potential clients orally, by recording, in writing, or
electronically (for example, via the internet or e-mail). Specify the timing of
disclosures to clients and potential clients. Provide the URL for electronic
disclosures. Include copies of all written and/or electronic disclosures in
response to section 6; do not include copies of the disclosures here.

Section 6.

Disclosures

Guidelines. Generally. The Agency shall make mandatory disclosures prior to providing any
information to or obtaining any information from a client or potential client, and
prior to providing any counseling services. The Agency may use more than one
form to communicate the required disclosures, including intake sheets, client
agreements, welcome letters or similar documents, but one form is preferable.
The written form and the electronic form, if any, must be consistent.
Mandatory disclosures. The list of mandatory disclosures includes:
(1) The Agency’s fee policy, including any fees associated with generation of the
certificate;
(2) The Agency’s policies enabling clients to obtain counseling services for free or
at reduced rates based upon the client’s lack of ability to pay. To the extent the

15

Agency publishes information concerning its fees on the internet, such fee
information must include the Agency’s policies enabling clients to obtain
counseling for free or at reduced rates based upon the client’s lack of ability to pay;
(3) The Agency’s policy to provide free bilingual counseling services or
professional interpreter assistance to any limited English proficient client;
(4) The Agency’s funding sources;
(5) The counselors’ qualifications;
(6) The potential impacts on credit reports of all alternatives the Agency may
discuss with the client;
(7) The Agency’s policy prohibiting it from paying or receiving referral fees for
the referral of clients, except under a fair share agreement;
(8) The Agency’s obligation to provide a certificate to the client promptly upon the
completion of counseling services;
(9) A statement that the client has the opportunity to negotiate an alternative
payment schedule with regard to each unsecured consumer debt under terms as set
forth in 11 U.S.C. § 502(k), and a statement whether or not the Agency will
provide this service. If the Agency does not provide this service, it shall disclose
that it may refer the client to another approved Agency, and shall disclose that
clients may incur additional fees in connection with such a referral;
(10) The fact that the Agency might disclose client information to the United
States Trustee in connection with the United States Trustee’s oversight of the
Agency, or during the investigation of complaints, during on-site visits, or during
quality of service reviews;
(11) The fact that the United States Trustee has reviewed only the Agency’s
credit counseling services (and, if applicable, its services as a provider of a
personal financial management instructional course pursuant to 11 U.S.C. §
111(d)), and the fact that the United States Trustee has neither reviewed nor
approved any other services the Agency provides to clients; and
(12) The fact that a client will receive a certificate only if the client completes
counseling services.
Specific instructions.
Provide copies of any and all disclosures the Agency supplies clients or potential clients in
connection with counseling services. If the Agency also provides an electronic disclosure,
provide the URL for the webpages evidencing those disclosures. Ensure that the Agency’s

16

responses to items 4.4(a), 4.5(a), and 4.6(a) describe the timing of the disclosures to the client
or potential client.
Section 7.

Administration of Debt Repayment Plans and the Safekeeping
and Payment of Client Funds

Guidelines.

This section applies only to Agencies offering debt repayment plans
(DRPs). If the Agency does not offer DRPs, continue to Section 8.
Financial security. The Agency must have adequate financial resources to
provide continuing support services for DRPs over the life of any plan, and
provide for the safekeeping of client funds.
Banking. The Agency shall deposit all client funds into a trust account insured
by a federal institution with respect to each client up to the maximum amount
allowable by the federal institution. Accounts shall be denominated as trust or
fiduciary accounts.
Accounting. The Agency shall keep and maintain books, accounts, and records
to provide a clear and readily understandable record of all business conducted
by the Agency.
Bonding. Agencies that offer DRPs must provide the following:
(a)

A surety bond payable to the United States in an amount which is the
lesser of: (1) two percent of the Agency’s prior year disbursements
made from trust accounts; or (2) equal to the average daily balance
maintained in all trust accounts for the six months prior to submission
of the application. At a minimum, the bond must be $5,000.

(b)

The Agency may receive an offset/credit in the surety bond amount
required by the United States Trustee as follows: (1) the Agency has
obtained a surety bond, or similar cash, securities, insurance (other than
employee fidelity insurance), or letter of credit, in compliance with the
licensing requirements of the state in which the Agency seeks approval
from the United States Trustee; (2) the surety bond, or similar cash,
securities, insurance (other than employee fidelity insurance), or letter
of credit provides protection for the clients of the Agency; (3) the surety
bond, or similar cash, securities, insurance, or letter of credit, must be
written in favor of the state or the appropriate state Agency; and (4) the
offset/credit is based on the annual disbursements or average daily bank
balance directly related to the clients in the particular state. See Example
1 below.
Offsets and credits shall be computed on a state by state basis. In
other words, a state bond can only be applied to offset the United States

17

Trustee bond to the maximum United States Trustee bond requirement
for that state. To the extent a state bond requirement exceeds the
maximum United States Trustee bond requirement attributable for that
state, the state bond cannot offset United States Trustee bond
requirements for any other states.
(c)

Proof of adequate employee bonding or fidelity insurance. The
amount shall be 50 percent of the surety bond amount calculated prior
to any offset/credit that the Agency may receive for state bonds. At a
minimum, the employee bond or fidelity insurance must be $5,000.

(d)

The Agency may receive an offset or credit against the employee bond
or fidelity insurance amount required by the United States Trustee if: (1)
the Agency has previously obtained an employee bond or fidelity
insurance in compliance with the requirements of the state in which the
Agency seeks approval from the United States Trustee; (2) the
deductible does not exceed a reasonable amount considering the
financial resources of the Agency; and (3) the offset or credit is the
lesser of (i) the principal amount of the employee bond or fidelity
insurance and (ii) the amount calculated based on the annual
disbursements or average daily bank balance directly related to the
clients in the particular state as set forth in (c) above. See Example 2
below.
Offsets and credits shall be computed on a state by state basis. In
other words, a state bond can be applied only to offset the United States
Trustee bond to the maximum United States Trustee bond requirement
for that state. To the extent a state bond requirement exceeds the
maximum United States Trustee bond requirement attributable for that
state, the state bond cannot offset United States Trustee bond
requirements for any other states.

Example 1: Surety Bond Offset/Credit
The Agency with total annual disbursements of $3,000,000 seeks approval in judicial districts
located in three states. The disbursements for the clients in each state are $1,000,000. State 1
has no bonding requirement; State 2 has a fixed surety bond of $15,000; and State 3 has a

18

bonding requirement of 10 percent of total annual disbursements. The Agency would calculate
the appropriate United States Trustee bonding requirement as follows:
State

Disbursements

1
2
3

$1,000,000
$1,000,000
$1,000,000

2% Bond
Requirement*
$20,000
$20,000
$20,000

State Bond
Amount

UST
Bond Amount

$0
$15,000
$100,000
Total

$20,000
$5,000
$0
$25,000

* In lieu of 2% of total annual disbursements, the Agency may use its average daily balance maintained in
all trust accounts for the six months prior to submission of the application.

The Agency must supply a bond calculation, similar to the example above,
demonstrating its offset/credit computation.
Example 2: Employee Bond/Fidelity Insurance Offset/Credit
The Agency with total annual disbursements of $2,000,000 seeks approval in judicial
districts located in two states. The disbursements for the clients in each state are
$1,000,000 each. State 1 has no employee bonding or fidelity insurance requirement and
State 2 has an employee bonding or fidelity insurance requirement of 10 percent of
monthly average disbursements ($83,000 per month). The Agency would calculate the
appropriate United States Trustee employee bonding or fidelity insurance requirement as
follows:
State

Disbursements

1
2

$1,000,000
$1,000,000

Surety Bond
Prior to Any
Offsets/Credits*
$20,000
$20,000

50% of
Surety Bond
$10,000
$10,000

State
Insurance
Amount

$0
$8,300
Total

UST
Insurance
Amount
$10,000
$1,700
$11,700

* In lieu of the surety bond calculation based on total annual disbursements, the Agency may use the
average daily balance maintained in all trust accounts for the six months prior to submission of the
application.

The Agency must provide an insurance calculation, similar to the example above,
demonstrating its offset/credit computation.
Administration by independent contractors. Subject to the exceptions below, if the
Agency has contracted with an independent contractor to administer any part of its
DRPs, the independent contractor shall either be an approved Agency or shall meet
specific bonding requirements. Specifically, an independent contractor that is not an
approved Agency shall be specifically covered under the Agency’s surety bond or:
(a) have a surety bond sufficient to meet the requirements set forth in (a) of the

19

Bonding section above, and
(b) agree in writing to allow the United States Trustee to audit the independent
contractor’s trust accounts for the DRPs administered on behalf of the Agency
and to review the independent contractor’s internal controls and administrative
procedures.
Exceptions to bonding requirement: There exist two exceptions to the bonding
requirement for independent contractors:
(a) If the independent contractor holds funds for transmission for 5 days or
less, then the amount of the required surety bond shall be $500,000; or
(b) If the independent contractor performs only electronic fund transfers on the
Agency’s behalf, then the independent contractor need not satisfy the bonding
and auditing requirements of this section during such time as the independent
contractor is authorized by the National Automated Clearing House
Association to participate in the Automated Clearing House system.
Specific instructions.
Item 7.1: Does the Agency offer DRPs? If the Agency currently offers DRPs to its clients,
then it must complete section 7 in its entirety.
If the Agency has ceased offering DRPs to new clients who receive counseling services from
the Agency, but continues to service, for earlier-counseled clients, any DRPs existing at the
date of the application, the Agency shall state the date on which the Agency ceased offering
DRPs to new clients. The Agency shall continue to maintain a surety bond payable to the
United States for the duration of such plans based on disbursements pursuant to those plans, as
set forth above.
Complete items 7.3 through 7.9 of the application.
Item 7.5: Independent contractors. To the extent the Agency uses any independent contractor
to administer, process, or execute any aspect of its DRPs or to handle client funds, it must
disclose those independent contractors.
Item 7.9(d): Independent contractor status. Consult the box checked in response to item 7.7 to
determine the necessary documents to attach as follows:
(a) The independent contractor performs only electronic fund transfers on the
Agency’s behalf, and no other functions. Exempt from bonding requirement.
Attach no documents;
(b) The independent contractor holds funds for transmission for five days or
less: Bonding requirement is $500,000. Attach evidence of the bond;

20

(c) The independent contractor is an approved Agency: Attach evidence of
the approved Agency’s bond;
(d) The independent contractor is covered under the Agency’s surety bond.
Include evidence of coverage under the Agency’s bond; or
(e) None of the above. Attach proof that the independent contractor
maintains a surety bond in a sufficient amount as provided above. Attach
a written acknowledgment from the independent contractor agreeing to allow
the United States Trustee or his/her designee to audit the trust accounts
maintained by the independent contractor and to review the independent
contractor’s internal controls and administrative procedures.
Section 8. Appendices
New applicants: Complete Appendices A, B, C, and D. Do not complete Appendix E.
Returning applicants: Complete Appendices A, B, C, D, and E.
Appendix A: Acknowledgments, Agreements, and Declarations in Support of
Application for Approval as a Nonprofit Budget and Credit Counseling Agency.
By executing and submitting the Application for Approval as a Nonprofit Budget and Credit
Counseling Agency, the Agency acknowledges and agrees to comply with the prohibitions,
limitations, and obligations set forth in Appendix A, Acknowledgments, Agreements, and
Declarations in Support of Application for Approval as a Nonprofit Budget and Credit
Counseling Agency.
Appendix B: Judicial Districts.
Check the box for each judicial district in which the Agency seeks approval. Each Agency is
responsible for ensuring that it complies with all applicable laws and regulations of the United
States and each state, district, commonwealth, or territory of the United States in which it
seeks approval from the United States Trustee.
After approval, the Agency must submit an amended application to add judicial districts. An
Agency that withdraws from any judicial district where it is approved must immediately
notify the United States Trustee in writing.
Appendix C: Business Locations.
List the Agency’s business locations and specify whether in-person services are available at
each listed location.

21

Appendix D: Matrix of Current Counselors.
The Agency shall use only counselors who possess adequate experience providing
credit counseling, which means that each counselor either:
(a)

holds a counselor certification and who has complied with all continuing
education requirements necessary to maintain his or her counselor certification;
or

(b)

has successfully completed a course of study and worked a minimum of six
months in a related area such as personal finance, budgeting, or credit or debt
management. A course of study shall include training in counseling skills,
personal finance, budgeting, or credit or debt management. A counselor shall
also receive annual continuing education in the areas of counseling skills,
personal finance, budgeting, or credit or debt management.

Certification and experience. A counselor shall be deemed to have adequate training
and experience to provide credit counseling and budget analysis if the counselor is
certified by a recognized independent organization, or has successfully completed a
course of study acceptable to the United States Trustee and has worked a minimum of
six months in a related area, including personal finance, budgeting, and debt
management. The United States Trustee does not endorse any specific course or
certification program.
With regard to each counselor who has completed a course of study, attach a
statement to Appendix D setting forth the name and provider of the course, an outline
of the course materials, and the criteria for passing the course. With regard to each
counselor who is certified by an independent organization, attach a statement to
Appendix D setting forth the organization’s name, contact information, and the
criteria for obtaining the certification.
Criminal background checks. The Agency shall conduct a criminal background check
at least every five years for each person providing counseling services. A “criminal
background check” means a report generated by a state law enforcement authority
disclosing the entire state criminal history record, if any, of the counselor for whom
the criminal background check is sought, for every state where the counselor has
resided or worked during any part of the immediately preceding five years. If a
criminal background check is not available for, or is not authorized by state law in,
each of the states where the counselor has resided or worked during any part of the
immediately preceding five years, the Agency shall instead obtain at least every five
years a sworn statement from each counselor attesting to whether the counselor has
been convicted of a felony, or a crime involving fraud, dishonesty, or false statements.
The Agency shall not substitute a statement in lieu of a criminal background check
unless a criminal background check is not available for, or is not authorized by state
law in, each of the states where the counselor has resided or worked during any part of
the immediately preceding five years.

22

The Agency shall not employ as a counselor anyone who has been convicted of any
felony or a crime involving fraud, dishonesty, or false statements, unless the United
States Trustee determines, upon review and in his or her discretion, the circumstances
warrant a waiver of this prohibition against employment.
Appendix E: Activity Report for Approved Credit Counseling Agencies.
Appendix E applies only to Agencies who have previously been approved by the United
States Trustee and are seeking re-approval. If the Agency has not yet been approved by the
United States Trustee as an approved Agency, do not submit Appendix E with the
application.
The relevant time periods for Appendix E are January 1-June 30 and July 1-December 31 of
each year. After the Agency has been approved, it must submit a completed Appendix E by
January 31 and July 31 of every year. Attach Appendix E for the most recent six-month period
when submitting an application.
Q16: Certificates issued at reduced cost. Include data only for fee reductions based on
ability to pay. Do not include reductions based on criteria independent of ability to
pay, such as arrangements with attorneys, referrals, or joint debtor discounts.
Section 9. Certification and Signature
The Agency has a continuing duty to promptly notify the United States Trustee of any
circumstances that would materially alter or change a response to any section of the
application, during the application process or otherwise. Notification must be in writing,
include all pages of the application and/or appendices that are affected by the change and a
newly executed “certification and signature.”
By signing the application, the Agency’s president, chairman, trustee, or other authorized
representative declares that he or she is authorized to complete the application on behalf of the
Agency; that he or she has read and knows the contents of the application and all enclosures
and attachments submitted; and that he or she affirms, under penalty of perjury, that all of the
representations and statements contained therein are true and correct to the best of that
individual’s knowledge, information, and belief.

23

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
Introduction. In accordance with 11 U.S.C. § 111, as implemented by Application Procedures and
Criteria for Approval of Nonprofit Budget and Credit Counseling Agencies by United States Trustees, 28
C.F.R. §§ 58.12 - 58.24 (the “Rule”), a nonprofit budget and credit counseling agency (an “Agency”)
seeking approval by the United States Trustee shall submit an application to the Executive Office for
United States Trustees (“EOUST”) in the form described below and in the accompanying Instructions. The
Agency shall provide all information and documents required by the EOUST or the United States Trustee
responsible for each judicial district in which the Agency seeks approval. Unless otherwise stated, the
application and appendices shall be typewritten1 using the space provided on the form, as well as
attachments if necessary.
An application is complete when all sections of the application have been addressed and copies of the
documents requested in the application are attached. Failure to submit a complete application may result
in processing delay or denial of the application. If additional space is required to complete a response,
attach a separate page with the name of the Agency, the federal tax identification number, and the item
number indicated on the top, right-side of the page.
Except where a “No Change” (“NC”) box appears, complete all items in the application, even if the
requested information has not changed since the most recent application. Do not leave any items blank.
If the Agency has no information to provide, state “N/A” with respect to the relevant item. Please see the
accompanying Instructions for detailed guidance on completing the application.
New Applicants. Check the box marked “New Applicant” in item 1.1. Complete every item in the
application. Do not check any of the “NC” boxes. Where an item provides alternatives for new applicants
and returning applicants, respond as directed for new applicants only.
Returning Applicants. Check the box marked “Returning Applicant” in item 1.1. Where an item
provides alternatives for new applicants and returning applicants, respond as directed for returning
applicants only.
Statement of No Change for Returning Applicants. Where a “NC” box appears beside an item, if the
Agency’s response to that item is identical to its response in the most recent application, the Agency may
check the “NC” box indicating no changes have occurred and continue to the next item. If an item does
not offer the option of checking a “NC” box, then the Agency must complete the item even if its response
has not changed since the previous application.
Burden Statement. Respondents are not required to complete this form unless it contains a valid OMB
number. The public reporting burden for this application is estimated to average ten hours for an initial
application and four hours for a re-application, including time for reviewing instructions, gathering
information, and completing the application. Comments regarding this burden estimate or any other aspect
“Typewritten” includes completion of the online fillable PDF form, or completion of the form using a word
processing application or a typewriter.
1

- 1-

of this application, including suggestions for reducing the burden, should be directed to the Executive
Office for United States Trustees, Credit Counseling Application Processing, 441 G Street, N.W., Suite
6150, Washington, D.C. 20530.
Section 1. General Information Concerning the Agency
1.1

Check only one box.
New Applicant.
Returning Applicant. Check here and provide the United States Trustee assigned Agency
number:

1.2

Name of Agency:

1.3

Federal Tax Identification Number of Agency:

1.4

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

1.5

Primary business address:

1.6

Street address:

Mailing address: (if different)

Telephone No.:

Fax No.:

Website(s):
1.7

____________________________________________________________

Principal contact for the Agency:
Name:
Email address:
If different from primary business address:
Telephone No.:

Fax No.:

address:

- 2-

1.8

Agency is:

1.9

State of organization:

Corporation
Partnership
Limited Liability Corp.

Institute of Higher Education
Limited Liability Partnership
Other:
Date of organization:

Section 2. Status as a Nonprofit Organization
2.1
NC

Nonprofit status.
(a) Is the Agency organized as a nonprofit entity pursuant to state law in the state of
organization?
Yes.
No.

NC

(b) Has the Agency received a tax-exempt determination from the Internal Revenue
Service?
Yes. Provide the date and basis (e.g., section 501(c)(3)) for the determination
here and continue to item 2.1(c).
No. Skip to item 2.1(d).
(c) Attach a copy of the most recent IRS Form 990, Return of Organizations Exempt
From Income Tax.
(d) State the Agency’s nonprofit purpose.

NC

NC

2.2

List all former names, f/k/a, and mailing addresses used by the Agency other than
those listed on items 1.2 and 1.4.
New Applicants: Supply the requested information for the most recent three years.
Returning Applicants: Supply the requested information for the most recent year.

NC

2.3

Identify the current officers and provide his or her: 1) title; 2) principal occupation;
3) employer name; 4) whether he or she has ever been convicted of a felony or a crime
involving fraud, dishonesty, or false statements; and 5) amount of direct or indirect

- 3-

compensation (including deferred compensation and other financial benefits). Attach
a resume for each officer who has served less than one year.

NC

2.4

Identify the current directors and trustees and provide his or her: 1) title; 2) principal
occupation; 3) employer name; 4) whether he or she has ever been convicted of a felony
or a crime involving fraud, dishonesty, or false statements; and 5) amount of direct or
indirect compensation (including deferred compensation and other financial benefits).
Attach a resume for each director or trustee who has served less than one year.

2.5

Material management changes.
New Applicants: Have any of the officers, directors, or trustees of the Agency changed
in the last three years?
Returning Applicants: Have any of the officers, directors, or trustees of the Agency
changed since the last application?
Yes. Complete items 2.6 and/or 2.7.
No. Continue to item 2.8.

2.6

Identify individuals who previously served as officers, but are no longer officers, and
provide his or her: 1) title; 2) term(s) in office; 3) the reason why he or she is no longer
an officer; and 4) whether he or she has ever been convicted of a felony or a crime
involving fraud, dishonesty, or false statements. State the amount of direct and indirect
compensation (including deferred compensation and other financial benefits) for each
individual.
New Applicants: Supply the requested information for the most recent three years.
Returning Applicants: Supply the requested information for the most recent year.

- 4-

2.7

Identify individuals who previously served as directors or trustees, but are no longer
directors or trustees, and provide his or her: 1) title; 2) term(s) in office; 3) the reason why
he or she is no longer a director or trustee; and 4) whether he or she has ever been
convicted of a felony or a crime involving fraud, dishonesty, or false statements. State the
amount of direct and indirect compensation (including deferred compensation and other
financial benefits) for each individual.
New Applicants: Supply the requested information for the most recent three years.
Returning Applicants: Supply the requested information for the most recent year.

2.8

Identify individuals who currently serve as directors or officers, but also have direct or
indirect financial or operational control in any other approved non-profit and budget credit
counseling agencies or approved providers of a personal financial management instructional
course, and provide his or her: 1) name; 2) title; 3) scope of involvement; and 4) amount of
direct and indirect compensation (including deferred compensation and other financial
benefits).
New Applicants: Supply the requested information for the most recent three years.
Returning Applicants: Supply the requested information for the most recent year.

2.9

Contracts and Referrals.
(a) Referrals to the Agency. Identify each individual or entity that regularly refers
clients to the Agency, and provide the following: 1) the individual or entity’s mailing
address, telephone number, e-mail address, and web address; 2) whether the referrals
are made pursuant to a fair share agreement, 3) whether referred clients receive a
discount from the Agency’s ordinary counseling fee; and 4) copies of any written
contracts or agreements. This includes all oral and written agreements with attorneys
who refer clients to the Agency.
New Applicants: Supply the requested information for the most recent two years.
Returning Applicants: Supply the requested information for the most recent year.

- 5-

(b) Referrals by the Agency. Identify each individual or entity to whom the Agency
regularly refers or has referred clients, and provide the following: 1) the individual or
entity’s mailing address, telephone number, e-mail address, and web address; 2) whether
the referrals are made pursuant to a fair share agreement; 3) whether referred clients
receive a discount from the Agency’s ordinary counseling fee; and 4) copies of any
written contracts or agreements. Include referrals for negotiation of alternative
repayment schedules pursuant to 11 U.S.C. § 502(k).
New Applicants: Supply the requested information for the most recent two years.
Returning Applicants: Supply the requested information for the most recent year.

(c) Contracts. To the extent the Agency has engaged in transactions with its officers,
directors, shareholders, affiliates, subsidiaries, or related individuals or entities, identify
the individual or entity and provide the following: 1) the individual or entity’s mailing
address, telephone number, e-mail address, and web address; and 2) copies of any
written contracts or agreements.
New Applicants: Supply the requested information for the most recent two years.
Returning Applicants: Supply the requested information for the most recent year.

NC

2.10

Independent contractors. Identify each independent contractor that performs
counseling services on behalf of the Agency or has access to, possession of, or control
over client funds. Provide the following: 1) the contractor’s mailing address, telephone
number, e- mail address, and web address; and 2) copies of any written contracts or
agreements.
If the Agency lists independent contractors with access to, possession of, or control over
client funds, check this box and complete section 7.

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Section 3. Quality, Experience, and Background in Providing Credit Counseling Services
3.1

How long has the Agency been in business?

3.2

How long has the Agency provided credit counseling services?
Years

3.3

Years

Months

Months

If the response to item 3.2 is less than 2 years, complete this item. Otherwise, check the
“N/A” box and continue to item 3.4.
N/A
For each location that serves clients, does the Agency employ at least one office
supervisor with experience and background in providing credit counseling services for
no fewer than two of the last five years?
Yes.
No.
Attach the following to the application:
(a)

A business plan;

(b)

The current year’s pro forma financial statements and cash flow projections
(including balance sheets, profit and loss statements, and statements of cash
flow); and

(c)

Identify the individual who will serve as the supervisor for each office offering
credit counseling services and attach a resume describing that individual’s
experience and educational background.

Names:
Documents are attached.
NC

3.4

List the Agency’s memberships, if any, with credit counseling associations. Do not list
accreditation or counselor certifications here. List accreditations in item 3.5 and
counselor certifications on Appendix D.

NC

3.5

List the Agency’s accreditation by accrediting organizations. Do not list counselor
certifications here. List those on Appendix D.

- 7-

NC

3.6

If the Agency’s accreditation was revoked, suspended, or lapsed at any time during the
last five years, state the dates and circumstances. If any counselor’s certification was
revoked, suspended, or lapsed at any time during the last five years, identify the
counselor and state the dates and circumstances.
New Applicants: Supply the requested information for the most recent five years.
Returning Applicants: Supply the requested information for the most recent year.

NC

3.7

List each state in which the Agency is licensed or certified to conduct credit counseling
services. For each state identified, also identify the state regulatory body that issued the
license or certificate and the license or certificate number, if any.

3.8

(a) Attach the annual audited financial statements prepared in accordance with generally
accepted accounting principles. Only new applicants that have not yet commenced
operations and have no audited financial statements as of the application date may
provide unaudited financial statements, including balance sheets, statements of income
and retained earnings, and statements of changes in financial condition.
(b) Attach the most recent federal income tax return. If the Agency is a tax-exempt
organization, attach the most recent IRS Form 990, Return of Organizations Exempt
From Income Tax.
New Applicants: Attach the requested documentation for the most recent two years.
Returning Applicants: Attach the requested documentation for the most recent year.
Documents are attached.

NC

3.9

List all legal actions, proceedings, investigations, arbitrations, mediations, and potential
bond or other claims, whether pending or adjudicated, in which the Agency, any affiliate
listed in the response to item 2.9(c), or any officer, director, trustee, employee, or agent
of the Agency is a party, and the outcomes of any such actions.
New Applicants: Supply the requested information for the most recent three years.
Returning Applicants: Supply the requested information for the most recent year.

NC

3.10

List all audits, disciplinary or enforcement actions by any applicable tax, oversight,
licensing, registration, or certification body against the Agency, any affiliate listed in

- 8-

the response to item 2.9(c), or any officer, director, trustee, employee, or agent of the
Agency, and the outcomes of any such actions.
New Applicants: Supply the requested information for the most recent three years.
Returning Applicants: Supply the requested information for the most recent year.

NC

3.11

List and provide any written correspondence between the Internal Revenue Service and
the Agency, or any affiliate listed in the response to item 2.9(c), that addresses issues
relating to the determination of the Agency’s tax-exempt status, examination, compliance
or audit.
New Applicants: Supply the requested information for the most recent three years.
Returning Applicants: Supply the requested information for the most recent year.

3.12

Continuing obligation to update. If any action described in items 3.6, 3.9 or 3.10
occurs while the application is pending, or the status of any existing action described in
items 3.6, 3.9 or 3.10 changes while the application is pending, the Agency must
promptly notify the United States Trustee at the address identified in the Instructions. In
addition, if the Agency or an affiliate sends or receives any correspondence described in
item 3.11 while the application is pending, the Agency shall provide that correspondence
to the United States Trustee.
I certify that I will update the United States Trustee under the circumstances
described above.

Section 4. Credit Counseling Methods and Curriculum
Counseling Methods:
In-Person:
Yes
Languages Offered:

Telephone:
No

Yes

Internet:
No

Languages Offered:

- 9-

Yes
Languages Offered:

No

NC

4.1

State the average duration of a credit counseling session in hours and minutes.
In-person:

Telephone:

Internet:

NC

4.2

List all other counseling services that the Agency provides.

NC

4.3

List the number of referrals of clients or potential clients for counseling based on limited
English proficiency, and identify the languages, other than English, requested by such
clients or potential clients.
New Applicants: Supply the requested information for the most recent two years.
Returning Applicants: Supply the requested information for the most recent year.

Sections 4.4 - 4.6: Counseling Methods and Procedures
Please see the Instructions before completing this section for required information and guidelines.
New Applicants: Complete each applicable item. Supply responses on a separate
attachment. An Agency that seeks approval to provide more than one delivery method
shall provide a complete response for each delivery method.
Returning Applicants: If the Agency has made no changes to its counseling methods or
procedures since the previous application was approved, check the “NC” box where
applicable and proceed to item 4.7. The Agency shall not unilaterally change its
counseling methods or procedures without prior United States Trustee approval.
NC

4.4

In-person counseling. Describe the counseling process, beginning with the process of
providing information to or obtaining information from a client or potential client, and
ending with certificate issuance. Include the following elements:
(a)

The process of obtaining client information and providing mandatory disclosures;

(b)

The substance of the counseling services; and

(c)

The certificate issuance process, including the timing of certificate issuance and
the Agency’s policies concerning which personnel may issue certificates.

- 10 -

NC

NC

4.5

4.6

Telephone counseling. Describe the counseling process, beginning with the process of
providing information to or obtaining information from a client or potential client, and
ending with certificate issuance. Include the following elements:
(a)

The process of obtaining client information and providing mandatory disclosures;

(b)

The substance of the counseling services;

(c)

The Agency’s experience and proficiency in providing counseling services over
the telephone;

(d)

The Agency’s client identity verification processes;

(e)

The criteria by which the Agency determines that the client has completed the
counseling as it was designed. If the Agency provides automated telephone
counseling, describe the process by which the client engages in interaction with a
counselor;

(f)

How and when the Agency delivers the written analysis of the client’s current
financial condition to the client;

(g)

A complete response to items 4.5(d), (e), and (f) as to spouses receiving
joint counseling; and

(h)

The certificate issuance process, including the timing of certificate issuance and
the Agency’s policies concerning which personnel may issue certificates.

Internet counseling. Describe the counseling process, beginning with the process of
providing information to or obtaining information from a client or potential client, and
ending with certificate issuance. Include the following elements:
(a)

The process of obtaining client information and providing mandatory disclosures;

(b)

The substance of the counseling services;

(c)

The Agency’s experience and proficiency in providing counseling services over
the Internet;

(d)

The Agency’s client identity verification processes;

(e)

The criteria by which the Agency determines that the client has completed the
counseling as it was designed, including the process by which the client engages
in interaction with a counselor;

(f)

How and when the Agency delivers the written analysis of the client’s current
financial condition to the client;

(g)

A complete response to items 4.6(d), (e), and (f) as to spouses receiving
joint counseling;

(h)

The certificate issuance process, including the timing of certificate issuance and
the Agency’s policies concerning which personnel may issue certificates; and

- 11 -

(i)

NC

4.7

An explanation of any modification or change to any part of the online content
or program or mandatory interaction, if any, since the previous application was
approved.

Attach copies of written standards, manuals, procedures, or guidelines, if any, the Agency
supplies to its counselors relating to the matters set forth in sections 4.4 through 4.6.

Section 5. Fees and Fee Waivers
5.1

Fees.
(a) List all fees and contributions paid by the client in connection with credit counseling
services. Specify all fees for single or joint counseling and each delivery method.

(b) List any reduced rates and the reason for such reduction, including discounts or
special rates for clients referred by any attorney or law firm, for spouses who take the
counseling jointly, or any other reduction based on criteria other than ability to pay. The
Agency shall not unilaterally decrease its fee without prior notice to the United
States Trustee.

(c) List all attorneys or law firms from whom the Agency directly or indirectly accepts, or to
whom the Agency provides reduced rates or discounts (including coupons) in connection with
credit counseling services.

(d) Describe how the Agency discloses to clients its fees and reduced rates or discounts
identified in (a), (b), and (c) and describe the timing of such disclosures.

(e) If the Agency seeks fees in excess of $50 per client, describe the basis for the fee
increase and provide a cost-based justification. Please see the Instructions. The Agency
shall not unilaterally increase its fee without prior United States Trustee approval.

- 12 -

5.2

Fee waivers.
(a) Describe any and all fee waiver and fee reduction policies based on the client’s ability
to pay.

(b) Describe how the Agency discloses to the client its fee waiver or fee reduction
policies based on the client’s ability to pay, and describe the timing of disclosures.

Section 6. Disclosures
Attach copies of all disclosure form(s) that will be provided to clients. Please see the Instructions
for a complete list of mandatory disclosures.
Disclosure documents are attached.
Section 7. Administration of Debt Repayment Plans (DRPs) and the Safekeeping and Payment of
Client Funds
Please see the Instructions before completing this section for required information and guidelines.
7.1 Check the box describing the Agency’s DRPs:
The Agency currently offers DRPs. Complete the rest of section 7.
The Agency has ceased offering DRPs to new clients who receive credit
counseling from the Agency but continues to service DRPs that are existing as of
the date of this application. State the date on which the Agency ceased
and complete items 7.3 through 7.9.
offering DRPs to new clients
The Agency does not offer DRPs and does not service DRPs on behalf of any
clients. Skip to section 8.

- 13 -

NC

7.2

How long has the Agency offered DRPs?
months
years,

7.3

State the number of DRPs serviced within the last 12 months:

7.4

State the amount of funds distributed by the Agency to creditors within the last 12-month
period: $

7.5

Does the Agency use any independent contractors to administer or process any aspect of
its DRPs?

Yes. Continue to item 7.6.
No. Skip to item 7.8.
NC

7.6

Provide the name, address, telephone number, and e-mail address of the independent
contractor(s).

NC

7.7

Independent contractor status.
For each independent contractor listed in response to item 7.6, check one box
concerning the independent contractor’s status.
The independent contractor performs only electronic fund
transfers on the Agency’s behalf, and no other functions.
The independent contractor holds funds for transmission for 5 days or less.
The independent contractor is an approved Agency.
The independent contractor is covered under the Agency’s surety bond.
None of the above.

NC

7.8

List the names and addresses of each bank or financial institution at which the Agency
maintains an operating account or trust account in which client funds will be deposited
and withdrawn to pay respective creditors. Trust accounts must be denominated as
trust or fiduciary accounts.

7.9

Attach the following to the application:
(a)

Original surety bond payable to the United States of America, if not previously
provided, and copies of any state bonds, including any renewals;

(b)

Calculations used to determine the appropriate level of all required bonds;

(c)

Proof of adequate employee bonding or fidelity insurance, and any renewals;

- 14 -

NC

(d)

If the Agency identified an independent contractor in item 7.6, please see the
Instructions to identify what documents must be attached for item 7.9(d);

(e)

If the Agency listed an independent contractor in item 7.6, attach a copy of any
service agreements or contracts between the Agency and each independent
contractor; and

(f)

The first page of the most recent bank statement for each trust account identified
in item 7.8. If the Agency’s bank account information has not changed since the
most recent application was approved, check the “NC” box and do not include an
attachment.
Required documents for item 7.9 are attached.

Section 8. Appendices (to be completed and attached to the application)
New Applicants: Complete Appendices A, B, C, and D. Do not complete Appendix E.
Returning Applicants: Complete Appendices A, B, C, D, and E.
8.1

Appendix A: Acknowledgments, Agreements, and Declarations in Support of Application
for Approval as a Nonprofit Budget and Credit Counseling Agency.

8.2

Appendix B: Judicial Districts.

8.3

Appendix C: Business Locations.

8.4

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.

8.5

Appendix E: Activity Report for Approved Credit Counseling Agencies. If the Agency
has never been approved to provide counseling services, do not complete Appendix E.
Documents are attached.

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 application does not falsify, conceal, cover up by any trick, scheme or
device a material fact; the application does not make any materially false, fictitious or fraudulent statement
or representation; the documents provided with this application are authentic, complete, and accurate and
do not make any materially false, fictitious or fraudulent statement or representation; and all representations
are true and correct to the best of my knowledge, information, and belief.
Signature of President, Chairman, Trustee, or Other
Authorized Representative

Type or Print Name of Signer

Type or Print Title of Signer

Date

- 15 -

OMB No. 1105-0084 Approval Expires

Appendix A: Acknowledgments, Agreements, and Declarations in Support of
Application for Approval as a Nonprofit Budget and Credit Counseling Agency
(Application for Approval as a Nonprofit Budget and Credit Counseling Agency)

Name of Agency:
The Agency 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
Agency 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 Agency seeks approval from the
United States Trustee.

2.

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.

3.

It will make all records relating to the Agency’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 visits and customer service audits, notwithstanding the existence of any contrary
privacy policy or agreement.

4.

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 Agency’s operations and services.

5.

It shall immediately notify the United States Trustee, in writing, of any material changes, including
changes in the Agency’s name, structure, principal contact, management, counselors, physical
location, counseling services, fee policy including making or implementing any decreases in fees,
language services, or method of delivery.

6.

It shall immediately notify the United States Trustee, in writing, of any changes that render
inapplicable, inaccurate, incomplete, or misleading any statement it previously made in its application
or related materials, as well as any statement to the United States Trustee.

7.

It will immediately notify the United States Trustee if there arises: any legal action, proceeding,
investigation, arbitration, mediation, audit or examination by federal or state agencies (including the
Internal Revenue Service) that involve the Agency; a change in the Agency’s nonprofit status or
authorization to operate under state law; a claim against the Agency’s surety bonds or employee
fidelity insurance policies; or any claim or action in which the Agency or its officers, directors, or
employees is a party.

8.

It will seek permission from the United States Trustee by submitting an amended application before:
making any change in amount of or cancellation of any surety bond or fidelity insurance; engaging an
independent contractor to provide credit counseling services or allowing the independent contractor to
have access to, possession of or control over client funds; making or implementing any increase in
fees, contributions or payments received from clients for credit counseling services; making or
implementing any change in its fee policy; any expansion into additional federal judicial districts; or
making or implementing any material change in credit counseling services or any change to its
methods of delivery.

9.

It is organized and operated as a nonprofit entity and has an independent board of directors, board of
trustees, or other governing body the majority of which (i) are not relatives; (ii) are not employed by
the Agency, and (ii) do not directly or indirectly benefit financially from the outcome of the credit
counseling services provided by the Agency.

10.

No member of the board of directors or trustees, officer, or supervisor is a relative of an employee of
the United States Trustee; a panel or standing trustee in any federal judicial district where the Agency
is providing or is applying to provide credit counseling services; a federal judge or federal court
employee in any federal judicial district where the Agency is providing or is applying to provide
credit counseling services; or a certified public accountant that performs audits of the Agency’s trust
account.

11.

No Agency owner, employee, officer, insider or related party, or member of the board of trustees,
directors, or any other corporate governing body will receive any commissions, incentives, bonuses,
or benefits (monetary or non-monetary) of any kind based on the outcome of a credit counseling
session.

12.

It will provide counselors who have adequate experience and training to provide credit counseling
services, and who receive no commissions, incentives, bonuses, or benefits (monetary or nonmonetary) based on the outcome of a counseling session.

13.

It will conduct a criminal background check every five years for each person providing credit
counseling services. If a criminal background check is not available for, or is not authorized by state
law in each of the states where the counselor has resided or worked during any part of the
immediately preceding five years, the Agency shall obtain a sworn statement from each counselor, at
least every five years, which attests to whether the counselor has been convicted of a felony or a
crime involving fraud, dishonesty, or false statements. The Agency shall not employ as a counselor
anyone who has been convicted of any felony or any crime involving fraud, dishonesty, or false
statements, unless the United States Trustee determines circumstances warrant a waiver of this
prohibition against employment.

14.

It will provide adequate credit counseling services, including a written outline of available counseling
opportunities to resolve the client’s financial problems, and a written analysis of the client’s budget,
current financial condition, and the factors that caused such financial condition. Based on the
analysis of the client’s financial condition, it will assist the client in developing a plan to respond to
the problems without incurring negative amortization of debt.

15.

It will provide an opportunity to negotiate an alternative payment schedule with regard to each
unsecured consumer debt pursuant to 11 U.S.C. § 502(k), or if it is unable to provide such services, it
will refer the client to another approved Agency that does so in the applicable federal judicial district.

16.

It will not exclude any creditor from a debt repayment plan because the creditor declines to make a
“fair share” contribution to the Agency.

17.

Any fee, contribution, or payment received for credit counseling services will be reasonable in
amount, and the Agency will provide services without regard to a client’s ability to pay.

18.

It will not disclose or provide to a credit reporting agency information concerning whether an
individual has sought or received credit counseling services from the Agency; nor sell information
about the client to any third party without the client’s prior written permission; nor expose the client
to commercial advertising as part of the credit counseling services; nor market or sell financial
products or services during the credit counseling session (though it may generally discuss all
available financial products and services).

19.

Any forms, agreements, contracts or other materials provided to a client will not limit the client’s
right to seek damages against the Agency as set forth in 11 U.S.C. § 111(g)(2).

20.

If credit counseling services cannot be provided to a client for any reason, it will refer clients for
credit counseling services only to Agencies that are approved by the United States Trustee.
Page 2 of 3

21.

It will not enter into any referral agreements or receive any financial benefit that involves the Agency
paying to or receiving from any entity or person referral fees or compensation for the referral of
clients to or by the Agency, except under a “fair share” agreement.

22.

Any advertisement that refers to the United States Trustee’s approval for the Agency to provide credit
counseling services in compliance with the Bankruptcy Code shall only be phrased in the following
manner: “Approved to issue certificates in compliance with the Bankruptcy Code. Approval does
not endorse or assure the quality of an Agency’s services.”

23.

It will 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.

24.

It will send a certificate to the client, upon completion of credit counseling services, no later than one
business day after completion of counseling, and shall issue certificates only in the form approved by
the United States Trustee and only from the Certificate Generating System maintained by the United
States Trustee.

25.

It consents to the release and disclosure of the Agency’s name on the approved list and the
publication of the Agency’s contact information.

26.

If administering debt repayment plans, it has adequate financial resources to provide continuing
support services for debt repayment plans over the life of any plan and provide for safekeeping of
client funds; it maintains client trust accounts that are audited annually by an independent certified
public accounting firm, in accordance with generally accepted accounting principles as defined by the
American Institute of Certified Public Accountants and any Statement of Work prepared by the
United States Trustee; and has obtained the requisite surety bonds and employee bonding or fidelity
insurance.

27.

If it has contracted with another entity (“independent contractor”) to administer any part of its debt
repayment plan, the independent contractor either: (a) is approved by the United States Trustee as a
nonprofit budget and credit counseling agency; or (b) is specifically covered under the Agency’s
surety bond, or has a surety bond that meets the requirements of 28 C.F.R. § 58.23(d)(1). The
independent contractor shall also agree in writing to allow the United States Trustee to audit the trust
accounts maintained by the independent contractor and to review the independent contractor’s
internal controls and administrative procedures. However, if the independent contractor holds funds
for five days or less, then the amount of the independent contractor’s surety bond shall be $500,000.
Further, if the independent contractor performs only electronic fund transfers on the Agency’s behalf,
then the independent contractor need not satisfy the surety bonding and audit requirements of 28
C.F.R. § 58.23(d)(3)(i) during such time as the independent contractor is authorized by the National
Automated Clearing House Association to participate in the Automated Clearing House system.

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 President, Chairman, Trustee, or Other
Authorized Representative

Type or Print Name of Signer

________________________________________

___________________________________

Type or Print Title of Signer

Date

Page 3 of 3

Appendix B: Judicial Districts

OMB No. 1105-0084 Approval Expires

(Application for Approval as a Nonprofit Budget and Credit Counseling Agency)

Name of Agency: ______________________________________________________________
Check each federal judicial district for which the Agency requests approval:
Alaska

Louisiana, Eastern

Pennsylvania, Eastern

Arizona

Louisiana, Middle

Pennsylvania, Middle

Arkansas, Eastern

Louisiana, Western

Pennsylvania, Western

Arkansas, Western

Maine

Rhode Island

California, Central

Maryland

South Carolina

California, Eastern

Massachusetts

South Dakota

California, Northern

Michigan, Eastern

Tennessee, Eastern

California, Southern

Michigan, Western

Tennessee, Middle

Colorado

Minnesota

Tennessee, Western

Connecticut

Mississippi, Northern

Texas, Eastern

Delaware

Mississippi, Southern

Texas, Northern

District of Columbia

Missouri, Eastern

Texas, Southern

Florida, Middle

Missouri, Western

Texas, Western

Florida, Northern

Montana

Utah

Florida, Southern

Nebraska

Vermont

Georgia, Middle

Nevada

Virginia, Eastern

Georgia, Northern

New Hampshire

Virginia, Western

Georgia, Southern

New Jersey

Washington, Eastern

Hawaii

New Mexico

Washington, Western

Idaho

New York, Eastern

West Virginia, Northern

Illinois, Central

New York, Northern

West Virginia, Southern

Illinois, Northern

New York, Southern

Wisconsin, Eastern

Illinois, Southern

New York, Western

Wisconsin, Western

Indiana, Northern

North Dakota

Wyoming

Indiana, Southern

Ohio, Northern

Guam

Iowa, Northern

Ohio, Southern

Northern Mariana Islands

Iowa, Southern

Oklahoma, Eastern

Puerto Rico

Kansas

Oklahoma, Northern

Virgin Islands

Kentucky, Eastern

Oklahoma, Western

Kentucky, Western

Oregon

The federal judicial districts in Alabama and North Carolina are not covered by the United States Trustee
Program.

OMB No. 1105-0084 Approval Expires

Appendix C: Business Locations

(Application for Approval as a Nonprofit Budget and Credit Counseling Agency)

Name of Agency:__________________________________________________________________
Contact Information: (To be posted on the United States Trustee approved list)
Address:

Telephone number:

Web address:

Business Locations:
List all business locations and include telephone number and business hours. In the last
column, check the box if in-person counseling is available at the location.
ADDRESS
(include street, city, county and state)

TELEPHONE
NUMBER

BUSINESS
HOURS

IN-PERSON
COUNSELING
AVAILAB LE

Appendix D: Matrix of Current Counselors

(Application for Approval as a Nonprofit Budget and Credit Counseling Agency)

OMB No. 1105-0084
Approval Expires ________

Name of Agency:
Other business names used at this location, if any:
Street address:

10.

9.

8.

7.

6.

5.

4.

3.

2.

1.

__________

(Copy this page for
additional employees)

Counselor Names

Total number of
personnel at this
location:

Supervisor (check)
EDUCATION - Highest Degree Received (check one)
High School
A.D.
B.A./B.S.
Graduate (M.S., J.D., Ph.D.)
Other (specify)*
COUNSELOR CERTIFICATION (check all that apply)
Certified by Independent
Organization*
Course of Study*
CFP
RFC
CPA
EXPERIENCE (state years of experience)
Credit Counseling
Financial Management Financial Planning
Consumer Credit Education
Consumer Economics
Other (specify)*
BACKGROUND CHECK (state the year of the criminal background check and check if no conviction for any felony, or crime
involving fraud, dishonesty, or false statements)
Criminal Check (Year)
No Criminal Conviction
ANNUAL CONTINUING EDUCATION
State year of most recent
completion of continuing
education course.
* Disclose on separate page. See Section 8, Appendix D, of Instructions for additional detail.

OMB No. 1105-0084
Approval expires ___

Appendix E: Activity Report for Approved Credit Counseling Agencies
Please submit this report within 30 calendar days following the end of each six-month period.
Questions? Contact Executive Office for United States Trustees at (202) 514-4100, or [email protected].

Reporting Period: (Check one)

□July-December

□January-June

Year:

Agency No:
Name of Agency:
Contact Person:

E-Mail:
Someone who could answer USTP questions

Instructions: Please provide actual (not estimated) data for all clients counseled by the Agency this reporting
period. No cell should be left blank. If none, enter “0” in the cell.
New Clients this Reporting Period
Q1

Number of new pre-bankruptcy clients counseled this reporting period

Q2

Number of other new clients counseled this reporting period

Q3

Number of clients requesting counseling in language other than English*

Q4

Number of clients provided counseling in language other than English*

Q5

Number of hearing-impaired clients requesting counseling

Q6

Number of hearing-impaired clients provided counseling

* Specify languages on next page
Debt Repayment Plans (DRPs)
Q7

DRPs active at the start of this reporting period

Q8

DRPs active at the end of this reporting period

Q9

Of all new pre-bankruptcy clients seen this reporting period, number enrolled in DRPs

Q10

Of all other new clients seen this reporting period, number enrolled in DRPs

Q11

DRPs closed this reporting period with completed debt repayment plans

Q12

DRPs closed this reporting period without completed debt repayment plans

Q13

Percentage of new pre-bankruptcy new credit counseling clients enrolled in DRPs
(Q9÷ Q1) x 100

Q14

Percentage of other new credit counseling clients enrolled in DRPs

(Q10 ÷ Q2) x 100

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

Counseling Method
b

In-Person

Q15 Certificates issued at no cost

Telephone*

Q18

c

Total Fees or
Contributions

Internet*

Q16 Certificates issued at reduced cost

►a

Q17 Certificates issued at regular cost

►b

Total

(Q15a+Q16a+Q17a)

(Q15b+Q16b+Q17b)

(Q15c+Q16c+Q17c)

(Q18a+Q18b)

* The former method of delivery, “telephone/Internet,” has been eliminated. You must select either telephone or Internet based
on the primary method used for delivery of counseling services. Please see the Instructions for more information.

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.