UNITED STATES BANKRUPTCY COURT Eastern District of Michigan
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
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.