B2800 (Form 2800) - Disclosure Of Compensation Of Bankruptcy Petition Preparer
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1B2800 (Form 2800) (12/15)
United States Bankruptcy Court
_______________ District Of ________________
In re _______________________________________________
Case No. ____________
Debtor
Chapter _____________
DISCLOSURE OF COMPENSATION OF BANKRUPTCY PETITION PREPARER
[Must be filed with the petition if a bankruptcy petition preparer prepares the petition. 11 U.S.C. § 110(h)(2).]
1.
Under 11 U.S.C. § 110(h), I declare under penalty of perjury that I am not an attorney or employee of an
attorney, that I prepared or caused to be prepared one or more documents for filing by the above-named
debtor(s) in connection with this bankruptcy case, and that compensation paid to me within one year before
the filing of the bankruptcy petition, or agreed to be paid to me, for services rendered on behalf of the
debtor(s) in contemplation of or in connection with the bankruptcy case is as follows:
For document preparation services I have agreed to accept...............................
$______________
Prior to the filing of this statement I have received.............................................
$______________
Balance Due.........................................................................................................
$______________
2.
I have prepared or caused to be prepared the following documents (itemize):
and provided the following services (itemize):
3.
The source of the compensation paid to me was:
Debtor
Other (specify)
4.
The source of compensation to be paid to me is:
Debtor
Other (specify)
5.
The foregoing is a complete statement of any agreement or arrangement for payment to me for preparation
of the petition filed by the debtor(s) in this bankruptcy case.
6.
To my knowledge no other person has prepared for compensation a document for filing in connection with
this bankruptcy case except as listed below:
NAME
SOCIAL SECURITY NUMBER
________________________________ _ ______________________________
_________________
Signature
Social Security number of bankruptcy
Date
petition preparer*
________________________________ ___________________________________________________
Printed name and title, if any, of
Address
Bankruptcy Petition Preparer
* If the bankruptcy petition preparer is not an individual, state the Social Security number of the officer, principal,
responsible person or partner of the bankruptcy petition preparer. (Required by 11 U.S.C. § 110).
A bankruptcy petition preparer's failure to comply with the provisions of title 11 and the Federal Rules of
Bankruptcy Procedure may result in fines or imprisonment or both. 11 U.S.C. § 110; 18 U.S.C. § 156.
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