AO# (Rev. 3/17) Application—Provider of Personal Financial Management Course Page 1 

U.S. Bankruptcy Administrator

______________ District of _____________________

APPLICATION FOR APPROVAL AS A PROVIDER OF A PERSONAL FINANCIAL 

MANAGEMENT INSTRUCTIONAL COURSE

An application package is complete if all questions/items have been responded to and an original or 

conformed copy of the documents requested in the application are attached. Failure to file a 

complete application may result in the delay or denial of the application. 

Responses to the questions on this application are continuing and the applicant must 

promptly notify the Bankruptcy Administrator of any circumstances that would cause an 

answer to any question to change. 

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 additional guidance on 

completing each item. If additional space is required to complete an answer, attach a separate page 

with the name of the individual/organization, social security number/federal tax identification 

number, and the question number indicated on the top, right-side of the page. 

Section 1. General Information Concerning the Provider

1.1 Provider is seeking (a) initial approval (b) renewal of approval* 

 (c) amendment to original application dated 

*If (b) state any changes to answers from your previous application with an asterisk. 

1.2 Provider is a(n): Individual Unincorporated Association

	 	 Corporation

 Partnership 

 Limited Liability Corp. 

 Limited Liability Partnership 

 Other 

1.3 Name under which Provider will conduct business (including any d/b/a), including any and 

all names the Provider has used in the last three years (including any d/b/a, a/k/a, or f/k/a): 

1.4 Primary business address (including street and mailing address), including all addresses the 

 Provider has used in the last three years: 
AO# (Rev. 3/17) Application—Provider of Personal Financial Management Course Page 2 

1.5 State of organization: ________________________________ 

 Date of organization: ________________________________ 

1.6 Federal Tax ID No. or Social Security No.:_______________ 

Telephone No.: ____________________________________ 

 Fax No.:__________________________________________ 

 Website: ____________________________________________ 

 Email: ___________________________________________ 

1.7 Name, street address, telephone number, email address, website address and fax number 

 of the principal contact for the Provider. 

1.8 Name, street address, telephone number, email address, and fax number of the registered 

 agent for the Provider. 

1.9 List each judicial district for which the Provider requests approval. 

1.10 List all locations of branch and satellite offices, if any. For each office where courses will 

be provided to debtor students, provide the mailing address, street address, telephone 

number, fax number, business hours, email address, Internet website, and number of 

personnel employed at each location. 
AO# (Rev. 3/17) Application—Provider of Personal Financial Management Course Page 3 

Section 2. Provider Background, Certifications, and Management

2.1 How long has the Provider been in business? Years Months 

2.2 How long has the Provider conducted personal financial management instructional 

courses? Years Months 

2.3 If the response to Item 2.2 is less than two years, complete this item. Otherwise, 

state “N/A.” 

 For each location that provides personal financial management instructional courses, does 

 the Provider employ at least one office supervisor with experience and background in 

 providing personal financial management instructional courses for no fewer than two of 

 the last five years? 

 _____ Yes _____ No 

 If yes, 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. 

2.4 How many students have been taught by the Provider within the last 12-month period? 

2.5 Identify each owner, officer, director, partner, or trustee who served within the last three 

years and provide their title, term of office, street address, principal occupation, 

employment experience, amount of direct and/or indirect compensation (including 

deferred compensation), and state whether they have been convicted of a crime involving 

fraud, dishonesty, or false statements. Attach a resume for each officer, director or 

trustee who is currently serving the Provider. 

2.6 Identify each individual or entity who regularly refers debtor students to the Provider and 

provide the following: 1) the individual’s or entity’s street address, mailing address, 

telephone number, fax number, email address, and web address; 2) whether referred 

debtors receive a discount from the Provider’s ordinary instructional course fee; 3) whether 

the referrals are made pursuant to a fair share agreement and 4) a copy of any written 

contracts or agreements with such individual or entity. 
AO# (Rev. 3/17) Application—Provider of Personal Financial Management Course Page 4 

2.7 Identify each individual or entity to whom the Provider regularly refers debtor students, 

and provide the following: 1) the individual’s or entity’s street address, mailing address, 

telephone number, email address, and web address; and 2) a copy of any written contracts 

or agreements with such individual or entity. 

2.8 Identify each officer, director, shareholder, affiliate, subsidiary, or related individual or 

entity with whom the Provider has engaged in transactions within the last year, and with 

respect to each such individual or entity, provide the following: 1) the nature of the 

transaction; 2) the individual’s or entity’s street address, mailing address, telephone 

number, email address, and web address; and 3) a copy of any written contracts or 

agreements with such individual or entity. 

2.9 Identify each independent contractor that performs services on behalf of the Provider or 

provides goods and services to the Provider, and provide the following: 1) the 

contractor’s street address, mailing address, telephone number, email address, and web 

address; and 2) a copy of any written contracts or agreements with such contractor. 

2.10 Identify all affiliated businesses or subsidiaries of the Provider within the last three years, 

including those persons identified as owners, officers, directors, partners, and trustees of 

those affiliated business or subsidiaries; whether organized for profit or not for profit; and 

the location and the nature of the business of each such affiliate business or subsidiary. 

2.11 State the name of each business with which the Provider conducts business in which an 

owner, officer, director, employee, or insider of the Provider holds, directly or by 

nominee, an ownership or financial interest except for ownership of stock or shares in a 

publicly traded entity. 

2.12 Disclose any accreditations(s) or certification(s) by accrediting or certifying organizations. 

Do not list instructor certifications here. 
AO# (Rev. 3/17) Application—Provider of Personal Financial Management Course Page 5 

2.13 If, at any time, the Provider’s accreditation or certification was revoked or suspended, or 

lapsed, within the last five years, disclose when and why. If any instructor’s certification 

was revoked, suspended, or lapsed at any time during the last five years, identify the 

instructor and state when and why. 

2.14 List each state in which the Provider is licensed to conduct business. For each state 

identified, also identify the state regulatory body that issued the license or certificate and 

the license or certificate number, if any. 

2.15 List all legal actions, proceedings, investigations, arbitrations, mediations, audits by 

federal or state agencies, and potential bond or other claims in which the Provider, any 

affiliate listed in response to question 2.11 above, or any officer, director, trustee, 

employee, or agent of the Provider is a party, pending or adjudicated, within the last three 

calendar years, and any disposition. 

2.16 Disclose any prior or ongoing disciplinary or enforcement action by an applicable 

licensing, registration, or certification authority, court, or regulatory body against the 

Provider, any affiliate listed in response to question 2.11 above, or any owner, officer, 

director, partner, trustee, employee, or agent of the Provider, within the last three 

years. 
AO# (Rev. 3/17) Application—Provider of Personal Financial Management Course Page 6 

Section 3. Experience and Training of Instructors

3.1 Complete and attach Appendix A, Matrix of Instructor Experience, for each location 

that will be staffed by instructors providing courses to debtor students. Enter the 

supervisor’s/instructor’s name and other identifying information in the employee box and 

complete the information as instructed. Supply the Provider’s name, address, and federal 

tax identification or Social Security number on each matrix submitted. 

3.2 Attach an original or conformed copy of the following to the application: 

• Any written standards, procedures, or guidelines provided to instructors of 

the Provider’s course. 

3.3 Describe the Provider’s continuing education policy for instructors. 

Section 4. Learning Materials and Methodologies (Course Curriculum)

4.1 Identify the delivery methods for the Provider’s instructional courses and the languages in 

which each delivery method is offered. 

 In-Person: Yes_____ No_____ 

 Languages offered: 

 Telephone: Yes_____ No_____ 

 Languages offered: 

 Internet: Yes_____ No_____ 

 Languages offered: 

4.2 State the average duration of the course in hours. 

In-Person: Telephone: Internet: 

4.3 For each applicable method of instruction, describe the process of providing mandatory 

disclosures to debtors. 
AO# (Rev. 3/17) Application—Provider of Personal Financial Management Course Page 7 

4.4 For each applicable method of instruction, describe the Provider’s identity verification 

processes. 

4.5 For each applicable method of instruction, describe the procedures that will be employed to 

encourage the completion and submission of course evaluation forms by student debtors. 

4.6 If providing courses in-person, provide the following information: 

(a) Describe the Provider’s procedures for limiting class size to ensure the 

effective presentation of classroom materials. 

(b) Describe the Provider’s procedures for ensuring that an instructor is present 

to instruct and interact with debtors. 

4.7 If providing courses by telephone, provide the following information: 

(a) Describe the Provider’s experience and proficiency in providing such 

 courses. 

(b) Describe the Provider’s policies regarding the use of toll-free telephone 

 number. 

 (c) Describe the Provider’s procedures to ensure compliance with the 

 Americans with Disabilities Act (“ADA”) and to provide toll-free 

 telephone numbers for deaf and hearing-impaired debtors. 
AO# (Rev. 3/17) Application—Provider of Personal Financial Management Course Page 8 

 (d) Describe the Provider’s procedures for ensuring that an instructor is 

 telephonically present to instruct and interact with debtor students. 

 (e) State whether the telephonic course uses pre-recorded instruction. 

(f) Describe the Provider’s procedures for providing written a copy of the learning 

 materials to debtor students before the telephonic instruction session. 

(g) Describe the Provider’s procedures for measuring the time spent by debtors in 

 completing the instructional course. 

4.8 If providing courses by Internet, provide the following information: 

(a) Describe the Provider’s experience and proficiency in providing such courses. 

(b) Describe the Provider’s procedures to ensure compliance with the ADA and its 

 application to the Internet. 

(c) Describe the Provider’s procedures for ensuring that an instructor responds to a 

 debtor’s questions or comments within 24 hours. 

(d) Describe the Provider’s procedures for measuring the time spent by debtors in

 completing the instructional course. 
AO# (Rev. 3/17) Application—Provider of Personal Financial Management Course Page 9 

4.9 Provide the web address for any Internet personal financial management course, and 

 provide a test username and password for accessing the course materials online and any 

 necessary instructions for accessing the course materials online. Provide a copy of screen 

 shots for all Internet course materials. 

4.10 Protection of Personal Identifiable Information (“PII”). 

 PII is defined as “any information about an individual maintained by an agency, including 

 (1) any information that can be used to distinguish or trace an individual‘s identity, such as 

 name, social security number, date and place of birth, mother‘s maiden name, or biometric 

 records; and (2) any other information that is linked or linkable to an individual, such as 

 medical, educational, financial, and employment information.” Guide to Protecting the 

 Confidentiality of Personally Identifiable Information (PII) Recommendations of the 

 National Institute of Standards and Technology (McAllister, Grance and Scarfone) NIST 

 Special Publication 800-122 (2010).

 

 Attach a copy of written procedures and policies implemented by the Provider to maintain 

 the confidentiality of PII collected from clients, including the Provider’s incident response 

 plan in the event that this information is compromised. List the name(s) and contact 

 information for provider personnel responsible for maintenance of confidentiality of 

 PII collected from clients. 

4.11 Attach an original or conformed copy of the following to the application: course materials 

used for planning purposes and instructional materials that will be regularly provided to the 

student debtors whether the course is taught in a classroom, by telephone, or over the 

Internet. 

Section 5. Adequate Facilities

5.1 Complete and attach Appendix B, Provider Checklist for Adequacy of Facilities, for each 

classroom location. 
AO# (Rev. 3/17) Application—Provider of Personal Financial Management Course Page 10 

Section 6. Reasonableness of Fees

6.1 List all fees and contributions paid by the debtor in connection with the 

instructional course. 

6.2 List any reduced rates (such as discounts for debtors referred by certain law 

firms, or special rates for spouses who take the course together), based on 

criteria other than ability to pay. 

6.3 Describe any and all fee waiver and fee reduction policies based on the debtor’s 

ability to pay. 

6.4 Attach an original or conformed copy of the following to the application: a fee schedule or 

suggested contribution schedule for all fees and contributions to be paid by debtor students, 

including any fees charged for material or other items; and the Provider’s fee waiver policy. 

6.5 If the Provider seeks fees in excess of $50 per client, describe the basis for the fee increase 

and provide a cost-based justification. The Provider may not unilaterally increase its 

fee without prior approval from the Bankruptcy Administrator. 

Section 7. Disclosures, Tax Returns, and Tax Information Authorization 

7.1 Attach to the application an original or conformed copy of all disclosure forms that 

 will be provided to debtors. Please see the instructions for a complete list of required 

 disclosures. 

7.2 Attach to the application an original or conformed copy of the Provider’s income tax 

 returns for the two years immediately preceding the filing of the application. 

7.3 Complete and attach Appendix C, Tax Information Authorization. 
AO# (Rev. 3/17) Application—Provider of Personal Financial Management Course Page 11 

Section 8. Acknowledgments, Agreements, and Declarations

8.1 Complete and attach an originally executed Appendix D, Acknowledgments, 

 Agreements, and Declarations in Support of Application for Approval as a Provider 

 of a Personal Financial Management Instructional Course. 

Section 9. Certification and Signature

I declare under penalty of perjury that I am authorized to complete this application of 

behalf of the above-named entity; I have examined the contents of the application, 

enclosures, and other accompanying documents. I believe that all representations are true 

and correct to the best of my knowledge, information, and belief.

Signature of Owner, President, Chairperson, Trustee, or Type or Print Name of Signor

Other Authorized Official 

Type or Print Title of Signor Date 
Appendix A: Matrix of Instructor Experience

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

Course) 

Name of Provider:

Address: 

Federal Tax ID No. or Social Security No.: 

Debtor 

Education 

Teacher 

Qualifications

Employee #1 

Employee #2 

Employee #3 

Employee #4 

Employee #5 

Employee #6 

Employee #7 

Employee #8 

Employee #9 Employee #10 

EDUCATION - Highest Degree Received (check one) 

High School 	 	 	 	 		 	 	 	 	

A.D.

B.A./B.S.

M.S.

J.D.

Ph.D.

Other (disclose on

separate page)

CERTIFICATION (check all that apply)

NFCC 	 	 	 	 		 	 	 	 	

AICCA

CFP

AFC

COA

Other (disclose on

separate page)

EXPERIENCE (state years of experience)

Classroom 	 	 	 	 		 	 	 	 	

Personal Financial

Management

Consumer Credit

Education

Financial Planning
Consumer

Economics 	 	 	 	 		 	 	 	 	

Credit Counseling

Other (disclose on

separate page)
Appendix B: Provider Checklist for Adequacy of Facilities

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

Provider Name: 

Fed. Tax Id. or Social Security No.: 

Location Address: 

CHECK ONE REQUIRED ELEMENT EXPLANATION 

YES NO 

Handicapped accessible building and room. 

No steps at door entry or at wheelchair 

ramp, rail. Meets specifications of 

 ADA. 

YES NO 

Handicapped accessible restrooms. Meets ADA. 

 

YES NO 

Close to public transport. 

Location within 1⁄2 mile of bus stop or 

reasonable distance from public 

 transportation if available in the area. 

YES NO 

Convenient parking and physically 

challenged designated parking available. 

YES NO 

Facility meets standard building safety 

codes. 

YES NO Facility does not exceed occupancy 

requirements for safety, fire, or health 

codes, rules or laws. 

Occupancy permit for intended use and 

number of occupants. 

YES NO 

Facility meets fire/life and health codes, 

rules or regulations. 

Established exit, fire alarm, sprinkler, 

or safety requirements are met. 

YES NO 

Facility does not contain hazardous 

materials. 

Facility is free of hazardous materials 

according to federal, state, and local 

 environmental rules or regulations. 

YES NO 

Facility has adequate liability insurance 

coverage. 
THIS CHECKLIST IS NOT AN EXCLUSIVE OR EXHAUSTIVE LIST OF ELEMENTS THE 

BANKRUPTCY ADMINISTRATOR MAY CONSIDER IN DETERMINING WHETHER A FACILITY IS 

ADEQUATE.

I declare under penalty of perjury that I have reviewed the information provided on this checklist and it is 

true and correct to the best of my knowledge, information, and belief. 

Signature of Owner, President, Chairman, Trustee, or Type or Print Name of Signor

Other Authorized Official 

Type or Print Title of Signor Date 

*Internet or telephonic courses are not subject to these requirements
Appendix C 

TAX INFORMATION AUTHORIZATION

_________________________________________________________________ 

Name of Organization/Employer Identification Number 

_________________________________________________________________________ 

Address of the Organization 

Hereby authorizes the Internal Revenue Service to disclose its returns and return information (as 

that term is defined in I.R.C. §6103(b)) for the five (5) tax years prior to the date of this 

authorization, including, but not limited to, whether the organization is currently under 

examination for those years, or the status of a pending application for recognition of tax exempt 

status, to officers and employees of the Administrative Office of the United States Courts and its 

Bankruptcy Administrator Program. 

I certify that I have authority to execute this tax information authorization on behalf of the 

organization named above. 

Name: ______________________________________________ 

Title: ______________________________________________ 

Signature: ______________________________________________ 

Date: ______________________________________________ 

Note: Treasury Regulations require that this authorization be received within 60 days of its 

execution by the taxpayer.
Appendix D

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

Course) 

Acknowledgments, Agreements, and Declarations 

in Support of Application for Approval as a 

Provider of a Personal Financial Management 

Instructional Course 

Name of Provider: 

The Provider hereby assures and certifies compliance with all applicable federal 

statutes, regulations, policies, guidelines, and requirements including, but not limited to, 11 

U.S.C. §§109(h) and 111. The Provider also specifically assures, certifies, and agrees that: 

1. It is in compliance with all applicable laws and regulations of the United States ant 

the state in which the Provider seeks approval from the Bankruptcy Administrator. 

2. No member of the board of directors or trustees, or owner, officer, manager, employee, 

or agent of the Provider is an employee of the U.S. Courts; a panel trustee in any federal 

judicial district where the Provider is providing or is applying to provide an instructional 

course; or person with a financial or familial connection to a panel trustee or an 

employee of the U.S. Courts. 

3. It will comply with the policies and directives of the Bankruptcy Administrator and the 

Administrative Office of the U.S. Courts, as may be issued from time to time. 

4. It will make all records related to the Provider’s compliance with 11 U.S.C. § 111 

available to the Bankruptcy Administrator upon request and cooperate with the 

Bankruptcy Administrator for any scheduled or unscheduled on-site visit or 

customer service audit. 

5. It will cooperate with the Bankruptcy Administrator and timely respond to any 

questions or inquiries concerning the Provider’s operations and services. 

6. It will immediately notify the Bankruptcy Administrator, in writing, of any material 

changes, including changes in the Provider’s name, structure, principal contact, 

management, physical location, instructional course, fee policy, language services, 

or methods of delivery. 

7. It will immediately notify the Bankruptcy Administrator, in writing, of any changes 

that render inapplicable, inaccurate, incomplete, or misleading any statement it 

previously made in its application or related materials, as well as any statement to 

the Bankruptcy Administrator. 
8. Its personnel will have adequate experience and training to provide effective 

instruction and services. 

9. Its learning materials and methodologies are designed to assist debtors in 

understanding personal financial management and are consistent with stated 

objectives directly related to the goals of such instructional course. 

10. It will conduct a criminal background check every five years for each person 

providing instruction in personal financial management and shall not employ as an 

instructor anyone who has been convicted of a crime involving fraud, dishonesty, or 

false statements. 

11. Any fee, contribution, or payment received for education services will be reasonable in 

amount, and the Provider will provide services without regard to a student debtor’s 

ability to pay. 

12. It will not enter into any referral agreements or receive any financial benefit that 

involves the Provider paying to or receiving from any entity or person referral fees or 

compensation for the referral of debtors to or by the Provider. 

13. It will not provide legal advice to debtor students. 

14. It will not contact any debtor student utilizing the United States Postal Service, or other 

mail carrier, or electronic mail for the purpose of soliciting debtors to utilize the provider's 

instructional course, unless: 

(a) Such solicitations include the phrase “This is an advertisement for services” or “This is 

a solicitation” prominently displayed at the beginning of each page of the solicitation, and 

in a font size larger than or equal to the largest font size otherwise used in the solicitation; 

and 

(b)Any such solicitations include only logos, seals, or similar marks that are substantially 

dissimilar to the logo, seal, or similar mark of any agency or court of the United States 

government, including but not limited to the Bankruptcy Administrator program. 

15. It will make the following disclosures to each debtor student before such debtor student 

pays a fee for the Provider’s instructional course: 

 (a) The Provider’s fee schedule, including any cost to the debtor student in addition 

to the course fee. 

 (b) A statement that the course is offered to debtor students without regard to the 

debtor student’s ability to pay. 

(c) The qualifications, including educational and training background, of the 

instructors. 

(d) A schedule of course dates, times, and locations, if applicable. 

(e) A statement that the Provider does not pay or receive fees or other 

consideration for the referral of debtor students to the Provider. 
(f) A statement that, upon completion of the course, the Provider will provide a 

certification of course completions to the debtor student. 

16. An approved Provider may state that it is approved to provide instructional counsel in 

personal financial management as required under the Bankruptcy Code. However, any 

advertisement that refers to such approval shall only be phrased in the following manner: 

“Approved to issue certificates evidencing completions of a personal financial 

management instructional course in compliance with the Bankruptcy Code. Approval 

does not endorse or assure the quality of a Provider’s services.” Approved Providers 

shall not use the Bankruptcy Administrator’s seal, the Bankruptcy Court’s seal, or any 

seal of the United States or a likeness thereof. 

17. It will assist the Bankruptcy Administrator in identifying and investigating suspected 

fraud and abuse by any party participating in the instructional course or bankruptcy 

process. 

18. Any forms, agreements, contracts, or other materials provided to debtors will not limit 

debtors’ right to seek damages against the Provider, as set forth in 11 U.S.C. 111(g)(2). 

19. It will refer debtors seeking an instructional course only to providers that have been 

approved by the Bankruptcy Administrator to provide such services. 

20. It will not disclose or provide to a credit reporting agency any information concerning 

whether a debtor has received or sought instruction concerning personal financial 

management from the Provider; nor sell information about any debtor to any third party 

without the debtor’s prior written approval; nor expose the debtor to commercial 

advertising as part of the instructional course; nor market or sell financial products or 

services during the instructional course (though it may generally discuss all available 

financial products and services). 

21. It will seek approval from the Bankruptcy Administrator by submitting an amended 

application before: engaging an independent contractor to provide an instructional course 

on behalf of the Provider; making or implementing any increase in fees, contributions, or 

payments received from debtors for an instructional course; making or implementing any 

change in its fee policy; any expansion into federal judicial districts; or making or 

implementing any material change in an instructional course or any change to its methods 

of delivery. 

22. It consents to the release and disclosure of the Provider’s name on the approved list and 

the publication of the Provider’s contact information. 

23. The Provider understands that failure to comply with any of the foregoing 

acknowledgements, agreements, and declarations may result in denial of the application 

or removal from the Bankruptcy Administrator’s list of approved providers. 
I HEREBY DECLARE under penalty of perjury that the foregoing representations are 

true and correct to the best of my knowledge, information, and belief.

I declare under penalty of perjury that I have reviewed the information provided on this checklist and it is true and 

correct to the best of my knowledge, information, and belief. 

Signature of Owner, President, Chairman, Trustee, or Type or Print Name 

Other Authorized Official 

Type or Print Title of Signer Date