EMS Monthly Report Data v.2022 (FCAA/IND/DUAL)
Use this form to report your agency's total EMS activity each month. Please report zeros for fields when applicable (do not leave blank) and submit your answers only once.
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Email *
Agency Name *
Month *
Select the month your are reporting from the drop-down.
# of Clients Offered *
Total number of clients that had EMS explained via phone/email/chat/etc. during the month you are reporting.
# of Clients Committed *
Total number of clients that agreed to EMS and signed or verbally committed to the EMS client disclosures during the month you are reporting, regardless of when they were originally offered.
# of Clients Enrolled *
Total number of clients that had their first EMS payment cleared for disbursement during the month you are reporting, regardless of when they were originally offered or committed to the program.
Dollar Amount of Disbursements *
Total dollar amount of payments sent to creditors for EMS clients during the month you are reporting, including disbursements for EMS clients that have reinstated their full DMP payments.
# of Clients Reinstated or Completed *
Total number of EMS clients that reinstated their full DMP payments or paid off their accounts during the month you are reporting.
# of Clients Cancelled *
Total number of EMS clients that stopped making payments to your agency and closed their accounts during the month you are reporting.
Total Debt of Active Clients Currently Managed *
The total debt currently under management for all active clients that used EMS even if they have moved back to regular DMP (All creditors not just EMS creditors).
A copy of your responses will be emailed to the address you provided.
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