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UNITED STATES BANKRUPTCY COURT Eastern District of Michigan

In Re:

Case No. Chapter: Debtor(s) / Hon.

DECLARATION UNDER PENALTY OF PERJURY FOR DEBTOR(S) WITHOUT AN ATTORNEY

The debtor(s) shall answer the following questions: 1. 2. Did you have help in preparing the documents for your bankruptcy filing? If you did have help, who helped you: Name Address City/State/Zip Telephone No. Soc. Sec. No. 3. If you did have help, what did you give or promise to give for this help? (Fill in all blanks). Money Paid $ What Value $ Property What Value $ Services

9Yes 9No

Owed $ 4.

Did you make any payment to the preparer for Court costs in connection with filing the petition? 9 Yes 9 No If so, how much $

I declare under penalty of perjury that the above statements are true.

Debtor's Signature Print Name: Address Phone # WARNING:

Debtor' Signature Print Name: Address Phone #

It is a federal crime to file a document containing false information in a federal court proceeding. Penalty for false declaration; Fine of not more than $250,000 or imprisonment for not more than 5 years or both - 18 U.S.C. §152 and U.S.C. §3571.