xxxx CC Application Appendix E

OMB No. 1105-0084
Approval expires 1/31/2016

Appendix E: Activity Report for Approved Credit Counseling Agencies
Please submit this report within 15 calendar days following the end of each six-month period.

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

Reporting Period: (Check one)

July-December

January-June

Year:
Agency No:

Name of Agency:
E-Mail:

Contact Person:
Someone who could answer USTP
questions regarding report

Instructions: Please provide actual (not estimated) data for all clients seen by your 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

Debt Management Plans (DMPs)
Q3

DMPs active at the start of this reporting period

Q4

DMPs active at the end of this reporting period

Q5

Of all new pre-bankruptcy clients seen this reporting period, how many enrolled in DMPs

Q6

Of all other new clients seen this reporting period, how many enrolled in DMPs

Q7

DMPs closed this reporting period with completed debt management plans

Q8

DMPs closed this reporting period without completed debt management plans

Q9

Percentage of new pre-bankruptcy new credit counseling clients enrolled in DMPs*

N

%

N

(Q5 ÷ Q1) x 100

Q10 Percentage of other new credit counseling clients enrolled in DMPs*

N

* If greater than 100%, please check your data

%
(Q6 ÷ Q2) x 100

Instructions: Please provide actual counts and total fees for all bankruptcy certificates issued by your 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
Counseling Method (Counts)
a
c
b
Internet
In-Person
Telephone*

Q14
Total Fees or
Contributions

Q11 Certificates issued at no cost
Q12 Certificates issued at reduced cost

►

a

Q13 Certificates issued at regular cost

►

b

Total
(Q11a+Q12a+Q13a) (Q11b+Q12b+Q13b) (Q11c+Q12c+Q13c)

(Q14a+Q14b)

* Includes both Telephone only and Telephone combined with Internet counseling.
January 9, 2007