Official Form 201 - Voluntary Petition For Non-Individuals Filing For Bankruptcy Page 4
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1
2
3
4Debtor
_______________________________________________________
Case number
_____________________________________
(if known)
Name
$0-$50,000
$1,000,001-$10 million
$500,000,001-$1 billion
Estimated liabilities
16.
$50,001-$100,000
$10,000,001-$50 million
$1,000,000,001-$10 billion
$100,001-$500,000
$50,000,001-$100 million
$10,000,000,001-$50 billion
$500,001-$1 million
$100,000,001-$500 million
More than $50 billion
Request for Relief, Declaration, and Signatures
WARNING -- Bankruptcy fraud is a serious crime. Making a false statement in connection with a bankruptcy case can result in fines up to
$500,000 or imprisonment for up to 20 years, or both. 18 U.S.C. §§ 152, 1341, 1519, and 3571.
Declaration and signature of
17.
The debtor requests relief in accordance with the chapter of title 11, United States Code, specified in this
authorized representative of
petition.
debtor
I have been authorized to file this petition on behalf of the debtor.
I have examined the information in this petition and have a reasonable belief that the information is true and
correct.
I declare under penalty of perjury that the foregoing is true and correct.
Executed on _________________
MM / DD / YYYY
_____________________________________________
_______________________________________________
Signature of authorized representative of debtor
Printed name
Title
_________________________________________
Signature of attorney
18.
Date
_____________________________________________
_________________
Signature of attorney for debtor
MM
/ DD / YYYY
_________________________________________________________________________________________________
Printed name
_________________________________________________________________________________________________
Firm name
_________________________________________________________________________________________________
Number
Street
____________________________________________________
____________ ______________________________
City
State
ZIP Code
____________________________________
__________________________________________
Contact phone
Email address
______________________________________________________ ____________
Bar number
State
Official Form 201
Voluntary Petition for Non-Individuals Filing for Bankruptcy
page 4
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