Bankruptcy Signature Form

BANKRUPTCY SIGNATURE FORM

This Bankruptcy Signature Form is executed on Execution Date: by Debtor Name: and Joint Debtor Name: in connection with Case Number: filed under Chapter: in the Bankruptcy Court for District: .

RECITALS

WHEREAS, Debtor has prepared and intends to file schedules, a statement of financial affairs, and related documents (collectively, the Schedules and Statements) in the referenced bankruptcy case as required by the applicable bankruptcy rules and statutes; and

WHEREAS, Debtor and Joint Debtor each have reviewed the information to be filed and wish to certify that such information is true, correct and complete to the best of their knowledge and belief;

WHEREAS, Debtor desires to authorize counsel, agent or other designated representative to file the Schedules and Statements, to receive notices and to act on Debtor's behalf in administrative matters related to the filing.

NOW, THEREFORE

In consideration of the foregoing recitals and the mutual covenants contained herein, the parties hereby agree as follows:

1. CERTIFICATIONS BY DEBTORS

1.1 Debtor and Joint Debtor each certify, under penalty of perjury pursuant to applicable law, that the information contained in the Schedules and Statements filed in the above-referenced case is true and correct to the best of their knowledge and belief. Debtor and Joint Debtor further certify that they have disclosed all assets, liabilities, income, expenditures, and transfers required by applicable bankruptcy rules.

1.2 Debtor and Joint Debtor acknowledge that making a materially false statement or concealing property in connection with a bankruptcy case may result in criminal prosecution and other civil penalties. By signing below, each certifies that they have reviewed the Schedules and Statements and that they understand the penalties for false statements.

1.3 Debtor and Joint Debtor certify the following specific attestations (check each box that applies):

I have examined the Schedules and Statements and believe them to be true and complete.

I have provided or made available to counsel all financial records and information necessary for preparation of the Schedules and Statements.

If applicable, I have completed the applicable means test and have disclosed all required information.

2. AUTHORIZATION TO COUNSEL / AGENT

2.1 Debtor and Joint Debtor authorize Counsel/Agent Name: , Bar Number: , to file the Schedules and Statements and to receive notices and service of pleadings on behalf of Debtor and Joint Debtor in the referenced case.

2.2 Counsel/Agent is authorized to submit any certifications required by the court and to take administrative actions reasonably necessary to prosecute the filing, including transmitting documents electronically and receiving electronic notices.

3. ACKNOWLEDGMENT OF PENALTIES

3.1 Debtor and Joint Debtor acknowledge that statements made herein and in the Schedules and Statements are subject to the penalties of perjury. Debtor and Joint Debtor further acknowledge that the court may impose sanctions, dismiss the case or refer matters to other authorities for investigation and prosecution where material misrepresentations or concealment of assets are found.

4. ELECTRONIC SIGNATURES AND FILING

4.1 Debtor and Joint Debtor consent to the use of electronic signatures and authorize counsel to affix electronic signatures to the Schedules and Statements and to file electronically on their behalf. Such electronic signatures shall be deemed original signatures for all purposes.

5. NOTICES

6. RELEASE AND AUTHORIZATION

6.1 Debtor and Joint Debtor authorize counsel and the court-appointed trustee to obtain and disclose information relevant to the administration of the estate, including tax returns, bank records, and third-party statements, as permitted by the applicable bankruptcy law. This authorization is limited to information necessary to verify the Schedules and Statements and to administer the bankruptcy estate.

7. GOVERNING LAW; ENTIRE AGREEMENT; SEVERABILITY

7.1 This Form shall be governed by and construed in accordance with the laws applicable to bankruptcy proceedings in the jurisdiction where the bankruptcy case is pending.

7.2 This Form constitutes the entire agreement between the parties with respect to its subject matter and supersedes any prior oral or written statements or agreements regarding the certifications and authorizations contained herein.

7.3 If any provision of this Form is held to be invalid or unenforceable, the remaining provisions shall remain in full force and effect.

8. AMENDMENT; WAIVER; COUNTERPARTS

8.1 This Form may be amended only by a written instrument executed by Debtor, Joint Debtor and Counsel/Agent. No waiver of any provision shall be effective unless in writing and signed by the party granting the waiver.

8.2 This Form may be executed in counterparts, each of which shall be deemed an original, and all of which together shall constitute one and the same instrument.

9. ADDITIONAL ACKNOWLEDGMENTS

9.1 Debtor acknowledges that certain personal identifiers (for example, social security number and financial account numbers) may be required on court filings and that Debtor has the responsibility to request redaction of such identifiers where permitted by the court's rules.

CERTIFICATION UNDER PENALTY OF PERJURY: By signing below, each undersigned certifies under penalty of perjury that the information provided in this Form and in the Schedules and Statements is true and correct to the best of his or her knowledge and belief.

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