xxxx Appendix F Revised

OMB No. 1105-0085
Approval expires 6/30/2009

Appendix F: Activity Report for Approved Debtor Education Providers
Please submit this report within 15 calendar days following the end of each six-month period.

http://www.adobe.com .
http://www.adobe.com .
http://www.adobe.com .

Questions? Contact United States Trustees at (202) 514-4100, Fax (202) 305-8536

Reporting Period: (Check one)

January-June

July-December

Year:
Provider No:

Name of Provider:
E-Mail:

Contact Person:
Someone who could answer USTP
questions regarding report

Instructions: Please provide actual (not estimated) data for all debtor students seen by your provider this reporting
period. No cell should be left blank. If none, enter “0” in the cell.
In-Person
Yes (%)

Evaluation Summary

Internet
Yes (%)

Telephone
Yes (%)

Q1

Goals were explained clearly.

%

%

%

Q2

Course topics were relevant to my life.

%

%

%

Q3

Learning materials were helpful.

%

%

%

Q4

Course Content was easy to understand.

%

%

%

Q5

Teacher was well prepared.

%

%

%

Q6

Teacher was helpful.

%

%

%

Q7

Training facility was comfortable.

%

%

%

Q8

Facility location was convenient.

%

%

%

Q9

I learned something I can use.

%

%

%

Q10

I will use a budget at home.

%

%

%

Q11

Number of Evaluation.

Instructions: Please provide actual counts and total fees for all bankruptcy certificates issued by your provider this
reporting period. No cell should be left blank. If none, enter “0” in the cell.
Q12

Total number of students receiving instruction during this reporting period

Debtor Education Certificates Issued this Reporting Period
Teaching Method (Counts)
a
c
b
Internet
In-Person
Telephone*

Q17

Total Fees or
Contributions

Q13

Certificates issued at no cost

Q14

Certificates issued at reduced cost

►

a

Q15

Certificates issued at regular cost

►

b

Q16

Total

0

0

0

(Q13a+Q14a+Q15a) (Q13b+Q14b+Q15b) (Q13c+Q14c+Q15c)

* Includes both Telephone only and Telephone combined with Internet instructional course.

$
(Q17a+Q17b)

0