Form B19
12/94
Form 19. CERTIFICATION AND SIGNATURE OF NON-ATTORNEY
BANKRUPTCY PETITION PREPARER (See 11 U.S.C. § 110)
[Caption as in Form 16B.]
CERTIFICATION AND SIGNATURE OF NON-ATTORNEY
BANKRUPTCY PETITION PREPARER (See 11 U.S.C. § 110)
I certify that I am a bankruptcy petition preparer as defined in 11 U.S.C. § 110, that I
prepared this document for compensation, and that I have provided the debtor with a copy of this
document.
_____________________________________________________
Printed or Typed Name of Bankruptcy Petition Preparer
________________________
Social Security No.
________________________
________________________
Address
Names and Social Security numbers of all other individuals who prepared or assisted in preparing
this document:
If more than one person prepared this document, attach additional signed sheets conforming to the
appropriate Official Form for each person.
X _______________________________________________
_______________
Signature of Bankruptcy Petition Preparer
Date
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