Official Form 106dec - Declaration About An Individual Debtor'S Schedules

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Fill in this information to identify your case:
Debtor 1
__________________________________________________________________
First Name
Middle Name
Last Name
Debtor 2
________________________________________________________________
(Spouse, if filing)
First Name
Middle Name
Last Name
__________
__________ District of __________
__________
United States Bankruptcy Court for the:
District of
Case number
___________________________________________
(If known)
Check if this is an
amended filing
Official Form 106Dec
Declaration About an Individual Debtor’s Schedules
12/15
If two married people are filing together, both are equally responsible for supplying correct information.
You must file this form whenever you file bankruptcy schedules or amended schedules. Making a false statement, concealing property, or
obtaining money or property by fraud in connection with a bankruptcy case can result in fines up to $250,000, or imprisonment for up to 20
years, or both. 18 U.S.C. §§ 152, 1341, 1519, and 3571.
Sign Below
Did you pay or agree to pay someone who is NOT an attorney to help you fill out bankruptcy forms?

No

Yes.
Name of person__________________________________________________. Attach Bankruptcy Petition Preparer’s Notice, Declaration, and
Signature (Official Form 119).
Under penalty of perjury, I declare that I have read the summary and schedules filed with this declaration and
that they are true and correct.

_____________________________
______________________________________________
Signature of Debtor 1
Signature of Debtor 2
_________________
Date
Date _________________
MM /
DD
/
YYYY
MM / DD /
YYYY
Official Form 106Dec
Declaration About an Individual Debtor’s Schedules
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