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Local Bankruptcy Form 102.1, Statement

[Caption as in Bankruptcy Official Form No. 16B]

Attorney Fee Disclosure Statement
The undersigned as attorney for the debtor(s) herein makes the following statements pursuant to 11 U.S.C. ' 329: 1. The total fee to be charged in this matter (not including filing fees) is $ has been paid leaving a balance of $ due. 2. The source of the compensation so paid or promised is . 3. I have not shared or agreed to share such compensation with any person, other than the members or regular associates of my law firm except . 4. The particulars of such sharing or agreement to share are . 5. I hereby apply for the award of the fees set forth herein. , of which $

Dated: Signature of Attorney for Debtor(s)