Free PA Western Bankruptcy Court #16-F Application for Refund + Order - Pennsylvania

UNITED STATES BANKRUPTCY COURT WESTERN DISTRICT OF PENNSYLVANIA In Re: ) ) ) ) ) CHAPTER Case No. Application for Refund

Debtor(s)

I, the undersigned petitioner, under penalty of perjury under the laws of the United States of America, declare (or certify, verify or state) that the following statements and information are true and correct: 1. Please check and complete the applicable subparagraph below: A. I am petitioning to receive the total amount of $______________, which is the sum of the overpayment of filing fee for the document filed in the above-named case on the date(s) of ___________________________ on behalf of the debtor(s). I am petitioning to receive the total amount of $______________, which is the sum of the overpayment of filing fee for the document filed in the above-named case on the date(s) of ___________________________ on behalf of the creditor, __________________________________ .

B.

2.

Receipt No. _______, for the overpayment of filing fee, was issued on _______________ in the amount of $___________. Refund should be sent to the following complete name and address:

3.

4.

I understand that, pursuant to 18 U.S.C. Section 152, I shall be fined not more than $5,000, or imprisoned not more than five (5) years, or both, if I have knowingly and fraudulently made any false statements in this document. I understand that it will take approximately 6-8 weeks to receive this refund.

5.

Date Executed: ______________________ Applicant's Signature: __________________________________________________________ Name of Applicant (Please type or print): ___________________________________________ Complete Address of Applicant (Please type or print): ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ Form #16-F

UNITED STATES BANKRUPTCY COURT WESTERN DISTRICT OF PENNSYLVANIA

In Re:

Debtor(s)

) ) ) ) )

CHAPTER Case No. Application for Refund

ORDER It is hereby ordered that the Clerk shall refund the filing fee in the amount of $______________, paid on ________________________ to ____________________________________________.

Dated:

By: Bankruptcy Judge

Form #16-F