Free Local Form #1 revised 2-28-06 - Pennsylvania

LOCAL BANKRUPTCY FORM NO. 1 IN THE UNITED STATES BANKRUPTCY COURT FOR THE WESTERN DISTRICT OF PENNSYLVANIA In Re Debtor DECLARATION RE: ELECTRONIC FILING OF PETITION, SCHEDULES & STATEMENTS PART I - DECLARATION OF PETITIONER
I, , and I, ________________________________________________________, the undersigned debtor, certify that the information I give to my attorney for the preparation of the petition, statements, schedules and mailing matrix is true and correct. I consent to my attorney sending my petition, this declaration, statements and schedules to the United States Bankruptcy Court. I understand that this DECLARATION RE: ELECTRONIC FILING is to be submitted to the Clerk once all schedules have been electronically docketed but, in any event, no later than 15 days following the date the petition was electronically filed unless the time is extended by order of court. I understand that failure to timely submit the signed original of this DECLARATION will result in dismissal of my case pursuant to 11 U.S.C. § 707(a)(3) without further notice. [If petitioner is an individual] I declare under penalty of perjury that the information provided in this petition and the social security number(s) listed below are true and correct: ________________________________ Name of Debtor ________________________________ Name of Joint Debtor Debtor has a social security number and it is: ________________________________ Check here if Debtor does not have a social security number: ______________ Joint Debtor has a social security number and it is: ________________________________ Check here if Joint Debtor does not have a social security number: ______________

BANKRUPTCY NO.

[If petitioner is a corporation or partnership] I declare under penalty of perjury that the information provided in this petition is true and correct, and that I have been authorized to file this petition on behalf of the debtor. The debtor requests relief in accordance with the chapter specified in this petition. Dated: Signed: ____________________________________ (Type Debtor name here ) Title: ______________________________________ (Corporate or Partnership Filing) ___________________________________________ Phone Number of Signer ____________________________________ Address of Signer ____________________________________ (Joint Debtor, if applicable, type name)

PART II - DECLARATION OF ATTORNEY
I further declare that before filing any document I will have examined the debtor's petition and that the information is complete and correct to the best of my knowledge, information and belief. The debtor will have signed this form before I submit the petition, schedules, statements and mailing matrix. I will give the debtor a copy of all forms and information to be filed with the United States Bankruptcy Court, and have followed all other requirements for electronic case filing. I further declare that I have examined the above debtor's petition, schedules, and statements and, to the best of my knowledge, information and belief, they are true, correct, and complete. If debtor is an individual, I further declare that I have informed the petitioner that [he or she] may proceed under chapter 7, 11, 12 or 13 of Title 11, United States Code, and have explained the relief available under each such chapter. This declaration is based on all information of which I have knowledge. Check box if debtor is a servicemember as defined by the Servicemembers Civil Relief Act of 2003. If debtor becomes entitled to protections from the Act during the bankruptcy case, he shall file an affidavit advising the Court within ten (10) days of the date of his change in status. Dated: ____________________________________ ____________________________________ Attorney for Debtor (Signature) ____________________________________ Typed Name ____________________________________ Address ____________________________________ Phone No. ____________________________________ List Bar I.D. and State of Admission