Application For Approval As A Provider Of A Personal Fin

OMB No. 1105-0085 Approval Expires

U.S. Department of Justice

Executive Office for United States Trustees

APPLICATION FOR APPROVAL AS A PROVIDER OF A PERSONAL FINANCIAL MANAGEMENT INSTRUCTIONAL COURSE

Introduction. In accordance with 11 U.S.C. § 111, as implemented by Application Procedures and Criteria for Approval of Providers of a Personal Financial Management Instructional Course by United States Trustees, 28 C.F.R. §§ 58.25 - 58.36 (the “Rule”), a provider of a personal financial management instructional course (a “Provider”) seeking approval by the United States Trustee shall submit an application to the Executive Office for United States Trustees (“EOUST”) in the form described below and in the accompanying Instructions. The Provider shall provide all information and documents required by the EOUST or the United States Trustee responsible for each judicial district in which the Provider seeks approval. Unless otherwise stated, the application and appendices shall be typewritten¹ using the space provided on the form, as well as attachments if necessary.

An application is complete when all sections of the application have been addressed and copies of the documents requested in the application are attached. Failure to file a complete application may result in processing delay or denial of the application. If additional space is required to complete a response, attach a separate page with the name of the Provider, the federal tax identification number, if applicable, and the item number indicated on the top, right-side of the page.

Except where a “No Change” (“NC”) box appears, complete all items in the application, even if the requested information has not changed since the most recent application. Do not leave any items blank. If the Provider has no information to provide, state “N/A” with respect to the relevant item. Please see the accompanying Instructions for detailed guidance on completing each item.

New Applicants. Check the box marked “New Applicant” in item 1.1. Complete every item in the application. Do not check any of the “NC” boxes. Where an item provides alternatives for new applicants and returning applicants, respond as directed for new applicants only.

Returning Applicants. Check the box marked “Returning Applicant” in item 1.1. Where an item provides alternatives for new applicants and returning applicants, respond as directed for returning applicants only.

Statement of No Change for Returning Applicants. Where a “NC” box appears beside an item, if the Provider’s response to that item is identical to its response in the most recent application, the Provider may check the “NC” box indicating no changes have occurred and continue to the next item. If an item does not offer the option of checking a “NC” box, then the Provider must complete the item even if its response has not changed since the previous application.

Burden Statement. Respondents are not required to complete this form unless it contains a valid OMB number. The public reporting burden for this application is estimated to average ten hours for an initial application and four hours for a re-application, including time for reviewing instructions, gathering information, and completing the application. Comments regarding this burden estimate or any or other aspect of this application, including suggestions for reducing the burden, should be directed to the

¹ “Typewritten” includes completion of the online fillable PDF form, or completion of the form using a word processing application or a typewriter.

Executive Office for United States Trustees, Debtor Education Application Processing, 441 G. Street, N.W., Suite 6150, Washington, DC 20548.

Section 1. General Information Concerning the Provider

1. Check only one box.

New Applicant . Continue to item 1.2.

Returning applicant . Check here and provide the United States Trustee assigned Provider number:

2. Name of Provider:

3. Federal Tax Identification Number of Provider, if applicable:

4. Additional names currently being used, including any d/b/a:

5. Primary business address:

6. Telephone No.: Fax No.:

Website(s):

7. Principal contact for the Provider:

Name: Email address:	Title:
If different from primary business address: Telephone No.: Fax No.: Mailing address:

1.8	Provider is:	Corporation	Institute of Higher Education
		Partnership	Limited Liability Partnership
		Limited Liability Corp.	Other:

^1.9 State of organization: Date of organization:

Section 2. Provider Names and Personnel

NC 2.1 List all former names, f/k/a, and mailing addresses used by the Provider other than those listed on items 1.2 and 1.4.

New Applicants : Supply the requested information for the most recent three years.

Returning Applicants : Supply the requested information for the most recent year.

NC 2.2 ^{Identify the current officers and provide his or her: 1) title, 2) principal occupation;}

3) employer name; and 4) amount of direct or indirect compensation (including deferred compensation and other financial benefits). Attach a resume for each officer who has served less than one year.

NC 2.3 ^{Identify the current directors and trustees and provide his or her: 1) title; 2) principal} occupation; 3) employer name; and 4) amount of direct or indirect compensation (including deferred compensation and other financial benefits). Attach a resume for each director or trustee who has served less than one year.

4. Material management changes.

New applicants: Have any of the officers, directors, or trustees of the Provider changed in the last three years?

Returning applicants: Have any of the officers, directors, or trustees of the Provider changed since the last application?

Yes. Complete items 2.5 and/or 2.6. No. Continue to item 2.7.

4. ^{Identify individuals who previously served as officers, but are no longer officers, and} provide his or her 1) title, 2) term(s) in office, and 3) the reason why he or she is no longer an officer. State the amount of direct and indirect compensation (including deferred compensation and other financial benefits) for each individual.

New Applicants: Supply the requested information for the most recent three years.

Returning Applicants: Supply the requested information for the most recent year.

4. ^{Identify individuals who previously served as directors or trustees , but are no longer} directors or trustees, and provide his or her 1) title, 2) term(s) in office, and 3) the reason why he or she is no longer a director or trustee. State the amount of direct and indirect compensation (including deferred compensation and other financial benefits) for each individual.

New Applicants: Supply the requested information for the most recent three years.

Returning Applicants: Supply the requested information for the most recent year.

NC 2.7 Contracts and Referrals.

1. Referrals to the Provider. Identify each individual or entity that regularly refers debtors to the Provider, and provide the following: 1) the individual or entity’s mailing address, telephone number, e-mail address, and web address; 2) whether referred debtors receive a discount from the Provider’s ordinary instructional course fee; and 3) copies of any written contracts or agreements. This includes all oral and written agreements with attorneys who refer clients to the Provider.

New Applicants: Supply the requested information for the most recent two years.

Returning Applicants: Supply the requested information for the most recent year.

2. Referrals by the Provider. Identify each individual or entity to whom the Provider regularly refers or has referred debtors, and provide the following: 1) the individual or entity’s mailing address, telephone number, e-mail address, and web address; 2) whether referred debtors receive a discount from the Provider’s ordinary instructional course fee; and 3) copies of any written contracts or agreements.

New Applicants: Supply the requested information for the most recent two years.

Returning Applicants: Supply the requested information for the most recent year.

3. Contracts. To the extent the Provider has engaged in transactions with its officers, directors, shareholders, affiliates, subsidiaries, or related individuals or entities, identify the individual or entity and provide the following: 1) the individual or entity’s mailing address, telephone number, e-mail address, and web address; and 2) copies of any written contracts or agreements.

New Applicants: Supply the requested information for the most recent two years.

Returning Applicants: Supply the requested information for the most recent year.

NC 2.8 ^{Independent Contractors. Identify each independent contractor that performs} instructional course services or other services on behalf of the Provider, and provide the following: 1) the contractor’s mailing address, telephone number, e-mail address, and web address; and 2) copies of any written contracts or agreements.

Section 3. Quality, Experience, and Background in Providing Personal Financial Management Instructional Courses

1. How long has the Provider been in business? _{Years Months}

2. How long has the Provider provided personal financial management instructional courses?

Years Months

3. If the response to item 3.2 is less than 2 years, complete this item. Otherwise, check the “N/A” box and continue to item 3.4.

N/A

For each location that serves debtors, does the Provider employ at least one office supervisor with experience and background in providing financial management instructional courses for no fewer than two of the last five years?

Yes.

No.

Attach the following to the application:

1. ^{Identify the individual who will serve as the supervisor for each office offering} instructional courses and attach a resume describing that individual’s experience and educational background.

Names:

Documents are attached.

NC 3.4 List the Provider’s accreditations by accrediting organizations. Do not list instructor certifications here. List those on Appendix D.

NC 3.5 ^{If the Provider’s accreditation was revoked, suspended, or lapsed at any time during the} last five years, state the dates and circumstances. If any instructor’s certification was revoked, suspended, or lapsed at any time during the last five years, identify the instructor and state the dates and circumstances.

New Applicants: Supply the requested information for the most recent five years.

Returning Applicants: Supply the requested information for the most recent year.

_{NC 3.6} List each state in which the Provider is licensed or certified to conduct financial education services. For each state identified, also identify the state regulatory body that issued the license or certificate and the license or certificate number, if any.

3.7 ^{Attach the most recent year-end financial statements prepared in accordance with} generally accepted accounting principles. If no audited financial statements were prepared, provide unaudited financial statements.

Documents are attached.

NC 3.8 List all legal actions, proceedings, investigations, arbitrations, mediations, and potential bond or other claims, whether pending or adjudicated, in which the Provider, any affiliate listed in the response to item 2.7(c), or any officer, director, trustee, employee, or agent of the Provider is a party, and the outcomes of any such actions.

New Applicants: Supply the requested information for the most recent three years.

Returning Applicants: Supply the requested information for the most recent year.

^NC 3.9 List all audits, disciplinary or enforcement actions by any applicable tax, oversight, licensing, registration, or certification body against the Provider, any affiliate listed in the response to item 2.7(c), or any officer, director, trustee, employee, or agent of the Provider, and the outcomes of any such actions.

New Applicants: Supply the requested information for the most recent three years.

Returning Applicants: Supply the requested information for the most recent year.

10. ^{Continuing obligation to update. If any action described in items 3.5, 3.8 or 3.9 occurs} while the application is pending, or the status of any existing action described in items 3.5, 3.8 or 3.9 changes while the application is pending, the Provider must promptly notify the United States Trustees at the address identified in the Instructions.

I certify that I will notify the United States Trustee under the circumstances described above.

Section 4. Learning Materials and Methodologies (Course Curriculum) Teaching Methods:

In-Person:		Telephone:		Internet:
Yes	No	Yes	No	Yes	No
Languages Offered:		Languages Offered:		Languages Offered:

NC 4.1 List all other instructional courses or services that the Provider provides.

NC 4.2 Describe the Provider’s continuing education policy for instructors.

NC 4.3 State the average duration of an instructional course in hours and minutes.

Classroom:

Telephone:

Internet:

_{NC 4.4} List the number of referrals of debtors for an instructional course based on limited English proficiency, and identify the languages, other than English, requested by such debtors.

New Applicants: Supply the requested information for the most recent two years.

Returning Applicants: Supply the requested information for the most recent year.

Sections 4.5 - 4.7: Instructional Methods and Procedures.

Please see the Instructions before completing this section for required information and guidelines.

New Applicants: Complete each applicable item. Supply responses on a separate attachment. A Provider that seeks approval to provide more than one delivery method shall provide a complete response for each delivery method.

Returning Applicants: If the Provider has made no changes to its instructional methods or procedures since the previous application as approved, check “NC” where applicable and proceed to item 4.8. The Provider shall not unilaterally change its curriculum without prior United States Trustee approval.

NC 4.5 ^{In-person instruction. Describe the instructional course process, beginning with the} process of providing information to or obtaining information from a debtor, and ending with certificate issuance. Include the following elements:

1. The process of obtaining debtor information and providing mandatory disclosures;

2. The substance of the instructional course;

3. The Provider’s policies concerning class size;

4. ^{The Provider’s procedures for ensuring that an instructor is present to instruct and} interact with debtors; and

5. ^{The certificate issuance process, including the timing of certificate issuance and} the Provider’s policies concerning which personnel may issue certificates.

NC 4.6 ^{Telephone instruction. Describe the instructional course process, beginning with the} process of providing information to or obtaining information from a debtor, and ending with certificate issuance. Include the following elements:

1. The process of obtaining debtor information and providing mandatory disclosures;

2. The substance of the instructional course;

3. ^{The Provider’s experience and proficiency in providing an instructional course} over the telephone;

4. The Provider’s debtor identity verification processes;

5. ^{The Provider’s procedures for ensuring that an instructor is telephonically present} to instruct and interact with debtors;

6. ^{The Provider’s procedures for providing learning materials to debtors before the} telephone instructional course session;

7. ^{The Provider’s procedures for incorporating tests into the curriculum that support} the learning materials, ensure completion of the course, and measure comprehension;

8. ^{The Provider’s procedures for ensuring review of tests prior to the completion of} the instructional course;

9. ^{The Provider’s procedures for ensuring direct oral communication from an} instructor by telephone or in person with all debtors who fail to complete the test in a satisfactory manner or who receive less than a 70% score;

10. ^{The criteria the Provider employs to measure the time spent by the debtor to} complete the instructional course;

11. ^{A complete response to items 4.6(d) - (j) as to spouses receiving joint instruction;} and

12. The certificate issuance process, including the timing of certificate issuance and the Provider’s policies concerning which personnel may issue certificates.

NC 4.7 ^{Internet instruction. Describe the instructional course process, beginning with the} process of providing information to or obtaining information from a debtor, and ending with certificate issuance. Include the following elements:

1. The process of obtaining debtor information and providing mandatory disclosures;

2. The substance of the instructional course;

3. ^{The Provider’s experience and proficiency in providing instructional courses over} the Internet;

4. The Provider’s debtor identity verification processes;

5. ^{The Provider’s procedures for incorporating tests into the curriculum that support} the learning materials, ensure completion of the course, and measure comprehension;

6. The Provider’s procedures for ensuring review of tests prior to the completion of the instructional course;

7. ^{The Provider’s procedures for ensuring direct communication from an instructor} by electronic mail, live chat, or telephone with all debtors who fail to complete the test in a satisfactory manner or who receive less than a 70% score;

8. ^{The criteria the Provider employs to measure the time spent by the debtor to} complete the instructional course;

9. ^{The Provider’s procedures for responding to a debtor’s questions or comments} within one business day;

10. A complete response to items 4.7(d)-(i) as to spouses receiving joint instruction; and

11. ^{The certificate issuance process, including the timing of certificate issuance and} the Provider’s policies concerning which personnel may issue certificates.

_NC 4.8 ^{Describe the Provider’s procedures concerning completion and submission of course} evaluation forms by debtors. Attach a copy of the proposed evaluation form. Note that certificate issuance may not be withheld based on a debtor’s failure to submit a course evaluation form or failure to obtain a passing grade on a quiz, examination, or test.

_{NC 4.9} Attach copies of written standards, manuals, procedures, or guidelines, if any, the Provider supplies to its instructors relating to the matters set forth in items 4.5 through 4.7.

Section 5. Fees and Fee Waivers.

1. Fees

(a) List all fees and contributions paid by the debtor in connection with the instructional course.

^{(b) List any reduced rates and the reason for such reduction, including discounts or special rates for debtors referred by any attorney or law firm, or} special rates for spouses who take the course together, based on criteria other than ability to pay. The Provider shall not unilaterally decrease its fee without prior notice to the United States Trustee.

^{(c) List all attorneys or law firms from whom the Provider directly or indirectly accepts, or to whom the Provider provides reduced rates or discounts (including coupons) in connection with financial education services}.

^{(d) Describe how the Provider discloses to debtors its fees, and} reduced rates or discounts identified in (a), (b), and (c) and describe the timing of disclosures.

(e) If the Provider seeks fees in excess of $50 per debtor, describe the basis for the fee increase and provide a cost-based justification. Please see the Instructions. The Provider shall not unilaterally increase its fee without prior United States Trustee approval.

2. Fee waivers.

(a) Describe any and all fee waiver and fee reduction policies based on the debtor’s ability to pay.

^{(b) Describe how the Provider discloses to the debtor its fee waiver} or fee reduction policies based on the debtor’s ability to pay, and describe the timing of disclosures.

Section 6. Disclosures

Attach copies of all disclosure form(s) that will be provided to debtors. Please see the Instructions for a complete list of mandatory disclosures.

Disclosure documents are attached.

Section 7. Appendices (to be completed and attached to the application)

New applicants: Complete Appendices A, B, C, and D. Do not complete Appendix E. Returning applicants: Complete Appendices A, B, C, D, and E.

_7.1 Appendix A: Acknowledgments, Agreements, and Declarations in Support of Application for Approval as a Provider of a Personal Financial Management Instructional Course.

7.2 Appendix B: Judicial Districts.

7.3 Appendix C: Business Locations.

7.4 ^{Appendix D: Matrix of Current Instructors. For each location listed on Appendix C that} will be staffed by instructors providing instructional courses to debtors, enter the instructor’s name in the employee box and complete the information as instructed.

7.5 ^{Appendix E: Activity Report for Approved Personal Financial Management Instructional} Course Providers. If the Provider has never been approved to provide an instructional course, do not complete Appendix E.

Documents are attached.

Section 8. Certification and Signature

I declare under penalty of perjury that I am authorized to complete this application on behalf of the above named organization; I have examined the contents of the application, enclosures, and other accompanying documents; the application does not falsify, conceal, cover up by any trick, scheme or device a material fact; the application does not make any materially false, fictitious or fraudulent statement or representation; the documents provided with this application are authentic, complete, and accurate and do not make any materially false, fictitious or fraudulent statement or representation; and all representations are true and correct to the best of my knowledge, information, and belief.

Signature of President, Chairman, Trustee, or Other Type or Print Name of Signer Authorized Representative

Type or Print Title of Signer Date

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