Appendix E: Activity Report for Approved Credit Counseli

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 ust.cc.help@usdoj.gov.

R eporting Period: (Check one) □July-December □January-June Year:

A gency No:

Name of Agency: E-Mail:

C ontact Person:

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

Q 1 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

D ebt 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

Q 10 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

	Counseling Method				Q18
	a In-Person	b Telephone*	c Internet*		Total Fees or
Q15 Certificates issued at no cost					Contributions
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.