xxxx DE Application Appendi E

_{Appendix E: Activity Report for Approved Debtor Education Providers}

OMB No. 1105-0085

Approval expires 6/30/2009

Evaluation Summary	In-Person Yes (%)	Telephone Yes (%)	Internet Yes (%)
Goals were explained clearly.	%	%	%
Course topics were relevant to my life.	%	%	%
Learning materials were helpful.	%	%	%
Course Content was easy to understand.	%	%	%
Teacher was well prepared.	%	%	%
Teacher was helpful.	%	%	%
Training facility was comfortable.	%	%	%
Facility location was convenient.	%	%	%
I learned something I can use.	%	%	%
I will use a budget at home.	%	%	%
Number of Evaluation.

Teaching Method (Counts)
a In-Person	b Telephone*	c Internet

http://www.adobe.com .

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

Please submit this report within 15 calendar days following the end of each six-month period.

Questions? Contact United States Trustees at (202) 514-4100

Reporting Period: (Check Name of Provider: Contact Person:	one) July-December January-June Year: Provider No:
	E-Mail: 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.
Q1 Q2 Q3 Q4 Q5 Q6 Q7 Q8 Q9 Q10 Q11
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 Q17 Total Fees or Q13 Certificates issued at no cost Contributions Q14 Certificates issued at reduced cost ► a Q15 Certificates issued at regular cost ► b Q16 Total (Q13a+Q14a+Q15a) (Q13b+Q14b+Q15b) (Q13c+Q14c+Q15c) (Q17a+Q17b) * Includes both Telephone only and Telephone combined with Internet instructional course.