Form B19 - Declaration And Signature Of Non-Attorney Bankruptcy Petition Preparer
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2B19 (Official Form 19) (12/07)
United States Bankruptcy Court
_____ District Of _______________
In re _______________________________,
Case No. _________________
Debtor
Chapter ______________
DECLARATION AND SIGNATURE OF NON-ATTORNEY
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 the accompanying document(s) listed below for compensation
and have provided the debtor with a copy of the document(s) and the attached notice as required
by 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 by that section.
Accompanying documents:
Printed or Typed Name and Title, if any, of
___________________________________
Bankruptcy Petition Preparer:
___________________________________
___________________________________
Social-Security No. of Bankruptcy Petition
___________________________________
Preparer (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
this 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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