Form B3b - Application For Waiver Of The Chapter 7 Filing Fee For Individuals Page 4
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5B3B (Official Form 3B) (11/11) -- Cont.
17. Have you previously filed for bankruptcy relief during the past eight years? Yes ___ No ___
Case Number (if
Year filed
Location of filing
Did you obtain a discharge? (if known)
known)
___________________
_______
______________
Yes ____
No ____ Don't know ____
___________________
_______
______________
Yes ____
No ____ Don't know ____
18. Please provide any other information that helps to explain why you are unable to pay the filing fee in
installments.
19. I (we) declare under penalty of perjury that I (we) cannot currently afford to pay the filing fee in full or
in installments and that the foregoing information is true and correct.
Executed on: ___________________
________________________________
Date
Signature of Debtor
___________________
________________________________
Date
Signature of Codebtor
------------------------------------------------------------------------------------------------------------------------------------------------------
DECLARATION AND SIGNATURE OF BANKRUPTCY PETITION PREPARER (See 11 U.S.C. § 110)
I declare under penalty of perjury that: (1) I am a bankruptcy petition preparer as defined in 11 U.S.C. § 110; (2) I prepared
this document for compensation and have provided the debtor with a copy of this document and the notices and information
required under 11 U.S.C. §§ 110(b), 110(h), and 342(b); and (3) if rules or guidelines have been promulgated pursuant to 11
U.S.C. § 110(h) setting a maximum fee for services chargeable by bankruptcy petition preparers, I have given the debtor
notice of the maximum amount before preparing any document for filing for a debtor or accepting any fee from the debtor, as
required under that section.
___________________________________________________________ __________________________
Printed or Typed Name and Title, if any, of Bankruptcy Petition Preparer
Social-Security No. (Required by
11 U.S.C. §110.)
If the bankruptcy petition preparer is not an individual, state the name, title (if any), address, and social-security number of
the officer, principal, responsible person, or partner who signs the document.
________________________________
________________________________
Address
x__________________________________________________
_____________________
Signature of Bankruptcy Petition Preparer
Date
Names and Social-Security numbers of all other individuals who prepared or assisted in preparing this document, unless the
bankruptcy petition preparer is not an individual:
If more than one person prepared this document, attach additional signed sheets conforming to the appropriate
Official Form for each person.
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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