Financial Education Courses

in compliance with the Bankruptcy Code.


Fields marked with * are mandatory!

   Contact Information
First Name   * ZIP   *
Middle Initial  Address   *
Last Name   * Apt # 
City   *
SSN    * State    *
Email  Phone   *
Cell  Fax 
   Personal Information
Gender  Date of Birth 
Open the calendar popup.
 *  (mm/dd/yyyy)
Language   * Reason for Debt   *
Marital Status   * Reason for Debt 
Race  Reason for Debt 
Living Condition   *    
   Spouse Information
First Name    SSN   
Middle Initial  Email 
Last Name    Date of Birth 
Open the calendar popup.
   Attorney/Paralegal Information
Firm Code    Bankruptcy Type 
Firm Name  Name 
Phone  Email 
Bankruptcy Case No    *
   Security Questions
Question 1: Answer 1:
Question 2: Answer 2:

I. You are you:
Under penalty of perjury, I/We certify to the best of my/our knowledge that all of the information on this application is true, correct, and complete and made in good faith. I/We certify that I/We will personally complete the pre-filing bankruptcy counseling or pre-discharge bankruptcy educational course. I/We understand that knowingly making a false or fraudulent statement or misrepresentation about my/our identity or completion of the course work is a violation of the requirements of Federal law.
Debtor Information
First Name 
Last Name 
Date of Birth 
General Information
City, State, ZIP  
II. Filing voluntary:
I/we are filing bankruptcy voluntarily and no one is forcing me/us to file against my/our will.
III. Not legal advice:
Although a counselor may answer general questions about bankruptcy, the agency does not provide legal or tax advice. If legal or tax advice is needed, you should seek the appropriate assistance from an attorney or tax professional.
IV. Legal Disclosure:
It is illegal for someone other than you to take�s online Pre-petition Bankruptcy Counseling Session. will not issue a certificate if it is found that the person taking this online Pre-petition Bankruptcy Counseling Session is not you.