XXXX DE Appendix E

Appendix E: Activity Report for Approved Providers

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

Questions? Contact Executive Office for United States Trustees at (202) 514-4100, or ust.de.help@usdoj.gov.

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

Provider No:

Name of Provider: E-Mail:

C ontact Person:

Someone who could answer USTP questions

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

Debtors Receiving Instruction this Reporting Period

Q1 Number of debtors receiving instruction this reporting period

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

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

Q4 Number of hearing-impaired debtors requesting instruction

Q 5 Number of hearing-impaired debtors provided instruction

* Specify languages on next page

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

Debtor Education Certificates Issued this Reporting Period

	Instructional Method				Q9
	a In-Person	b Telephone	c Internet		Total Fees or
Q6 Certificates issued at no cost					Contributions
Q7 Certificates issued at reduced cost				►a
Q8 Certificates issued at regular cost				►b
Total

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

Course Evaluation Summary:

For courses conducted during	In-Person			Telephone			Internet
Probationary or Annual Period	%Yes	%No		%Yes	%No		%Yes	%No
COURSE
Goals were explained clearly.
Course topics were relevant to my life.
Learning materials were helpful.
Course content was easy to understand.
INSTRUCTOR
Instructor was well prepared.
Instructor was helpful.
COURSE ENVIRONMENT
Training facility was comfortable.
Facility location was convenient.
COURSE RESULTS
I learned something I can use.
I will use a budget at home.
Languages Requested other than English* 1. 6. 2. 7. 3. 8. 4. 9. 5. 10. * If more than ten, please attach a list of additional languages requested.
Languages Provided other than English* 1. 6. 2. 7. 3. 8. 4. 9. 5. 10. * If more than ten, please attach a list of additional languages provided.