Form 280 - Disclosure Of Compensation Of Bankruptcy Petition Preparer
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1B280 (Form 280) (10/05)
United States Bankruptcy Court
_______________ District Of ________________
In re _____________________________
Debtor
Case No. ____________
Chapter _____________
DISCLOSURE OF COMPENSATION OF BANKRUPTCY PETITION PREPARER
[This form 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
x___________________________________
______________________________
_________________
Signature
Social Security number of bankruptcy
Date
____________________________________
petition preparer (If the bankruptcy
Printed name and title, if any, of Bankruptcy
petition preparer is not an individual,
Petition Preparer
state the Social Security number of the
Address:_____________________________
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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