Petition Preparers'S Notice, Declaration, And Signature - United States Page 2
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1
2Debtor 1
_______________________________________________________
Case number
_____________________________________
(if known)
First Name
Middle Name
Last Name
Part 2:
Declaration and Signature of the Bankruptcy Petition Preparer
Under penalty of perjury, I declare that:
I am a bankruptcy petition preparer or the officer, principal, responsible person, or partner of a bankruptcy petition preparer;
I or my firm prepared the documents listed below and gave the debtor a copy of them and the Notice to Debtor by Bankruptcy Petition
Preparer as required by 11 U.S.C. §§ 110(b), 110(h), and 342(b); and
if rules or guidelines are established according to 11 U.S.C. § 110(h) setting a maximum fee for services that bankruptcy petition
preparers may charge, I or my firm notified the debtor of the maximum amount before preparing any document for filing or before
accepting any fee from the debtor.
________________________________ ______________________
_______________________________________________________
Printed name
Title, if any
Firm name, if it applies
______________________________________________________
Number
Street
____________________________________ __________ ______________
______________________________
City
State
ZIP Code
Contact phone
I or my firm prepared the documents checked below and the completed declaration is made a part of each document that I check:
(Check all that apply.)
Voluntary Petition (Form 101)
Schedule I (Form 106I)
Chapter 11 Statement of Your Current Monthly
Income (Form 122B)
Statement About Your Social Security Numbers
Schedule J (Form 106J)
Chapter 13 Statement of Your Current Monthly
(Form 121)
Declaration About an Individual Debtor’s
Income and Calculation of Commitment Period
Summary of Your Assets and Liabilities and
Schedules (Form 106Dec)
(Form 122C-1)
Certain Statistical Information (Form 106Sum)
Statement of Financial Affairs (Form 107)
Chapter 13 Calculation of Your Disposable
Schedule A/B (Form 106A/B)
Income (Form 122C-2)
Statement of Intention for Individuals Filing
Schedule C (Form 106C)
Under Chapter 7 (Form 108)
Application to Pay Filing Fee in Installments
(Form 103A)
Chapter 7 Statement of Your Current
Schedule D (Form 106D)
Monthly Income (Form 122A-1)
Application to Have Chapter 7 Filing Fee
Schedule E/F (Form 106E/F)
Waived (Form 103B)
Statement of Exemption from Presumption
Schedule G (Form 106G)
of Abuse Under § 707(b)(2)
A list of names and addresses of all creditors
(Form 122A-1Supp)
(creditor or mailing matrix)
Schedule H (Form 106H)
Chapter 7 Means Test Calculation
Other _____________________________
(Form 122A-2)
Bankruptcy petition preparers must sign and give their Social Security numbers. If more than one bankruptcy petition preparer prepared the documents
to which this declaration applies, the signature and Social Security number of each preparer must be provided. 11 U.S.C. § 110.
8
_______________________________________________________________
___ ___ ___ ___ ___ ___ ___ ___ ___
Date
_________________
Signature of bankruptcy petition preparer or officer, principal, responsible
Social Security number of person who signed
MM / DD / YYYY
person, or partner
_______________________________________________________________
Printed name
8
_______________________________________________________________
___ ___ ___ ___ ___ ___ ___ ___ ___
Date
_________________
Signature of bankruptcy petition preparer or officer, principal, responsible
Social Security number of person who signed
MM / DD / YYYY
person, or partner
_______________________________________________________________
Printed name
Official Form 119
Bankruptcy Petition Preparer’s Notice, Declaration, and Signature
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