United States Bankruptcy Court
_______________ District Of _______________
In re _________________________,
Case No. _______________________
DECLARATION AND SIGNATURE OF NON-ATTORNEY
BANKRUPTCY PETITION PREPARER (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 for compensation and have provided the debtor with a copy of
that 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 by that section.
Printed or Typed Name of Bankruptcy Petition Preparer
If the bankruptcy petition preparer is not an individual, state the name, address, and social security number of the
officer, principal, responsible person or partner who signs this document.
Social Security No.
Signature of Bankruptcy Petition Preparer
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.