UNITED STATES BANKRUPTCY COURT
NORTHERN DISTRICT OF GEORGIA
Case No. _________
APPLICATION TO PAY FILING FEE IN INSTALLMENTS
FOR INDIVIDUALS IN CHAPTER 11 OR 13 CASES
1. In accordance with Fed. R. Bankr. P. 1006 and General Order No. 4-2005 (Bankr. N.D. Ga.,
October 5, 2005), I apply to pay the filing fee amounting to $_______ in no more than three (3)
2. I certify that I am unable to pay the filing fee except in installments.
3. I further certify that I will neither make any payment nor transfer any property for services in
connection with this case until the filing fee is paid in full.
4. I accept the following terms for the payment of the filing fee:
! First Installment of $_______, with the filing of the petition.
! Second Installment of at least one-half of the unpaid balance of the filing fee in the
amount of $_______, on or before 30 days from the date the bankruptcy petition
! Final Installment of the remaining unpaid balance of the filing fee in the amount of
$_______, on or before 60 days from the date the bankruptcy petition was filed.
5. I understand that if I fail to pay any fee installment when due my bankruptcy case will be
Signature of Attorney Date
Signature of Debtor Date
(In a joint case, both Debtors must sign)
Name of Attorney
Signature of Joint Debtor Date
DECLA RATION AND SIGNATURE OF NO N-ATTORNEY BANK RUPTC Y PETITION (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); (3) if rules or guidelines have been promulga