Fill and Sign the Justia Disclosure of Compensation of Bankruptcy Form

B 280 (10/05)Unit ed St at es Bankrupt cy Court _______________ Dist rict Of ________________ In re _____________________________ Debtor Case No. ____________ Chapter _____________ DISCLOSURE OF COMPENSATION OF BANKRUPTCY PETITION PREPARER [Must be filed with the petition if a bankruptcy petition pre parer prepares the petition. 11 U.S.C. § 110(h)(2).] 1. Under 11 U.S.C. § 110(h), I declare under penalty of perjury that I am not an attorney or employee of an attorney, that I pre pared or caused to be prepared one or more documents for filing by th e above-named debtor(s) in connection with this bankruptcy case, and that compensation paid to me within one year before the f iling of the bankruptcy petition, or agreed to be paid to me, for services rendered on behalf of the debtor(s) in contemplation of or in connection with the bankruptcy case is as follows: For document preparation services I have agreed to accept............................... $______________ Prior to the filing of this statement I have received............................................. $______________ Balance Due......................................................................................................... $______________ 2. I have prepared or caused to be pr epared the following documents (itemize): and provided the following services (itemize): 3. The source of the compensation paid to me was: Debtor Other (specify) 4. The source of compensation to be paid to me is: Debtor Other (specify) 5. The foregoing is a complete statement of any agreement or arra ngement for payment to me for preparation of the petition filed by the debtor(s) in this bankruptcy case. 6. To my knowledge no other person has prepared for compensation a document for filing in connection with this bankruptcy case except as listed below: NAME SOCIAL SECURITY NUMBER x___________________________________ ______________________________ _________________ Signature Social Security number of bankruptcy Date ____________________________________ petition preparer (If the bankruptcy Printed name and title, if any, of Bankrupt cy petition preparer is not an individual, Petition Preparer state the Social Security number of the Address:_____________________________ officer, principal, responsible person or partner of the bankruptcy petition preparer.) ____________________________________ (Required by 11 U.S.C. § 110.) -------------------------------------------------------------------------------------------------------------------------------------------------------------- ------------ A bankruptcy petition preparer's failure to comply with the prov isions 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.