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

LOCAL BANKRUPTCY FORM NO. 1A IN THE UNITED STATES BANKRUPTCY COURT FOR THE WESTERN DISTRICT OF PENNSYLVANIA In Re Debtor BANKRUPTCY NO.

DECLARATION RE: ELECTRONIC FILING OF PETITION, SCHEDULES & STATEMENTS FOR INDIVIDUAL DEBTOR NOT REPRESENTED BY COUNSEL

I, _________________________________________, and I, _________________________________________, the undersigned debtor, certify that the Bankruptcy petition, statements, schedules and mailing matrix presented to the Clerk for filing is true and correct. I understand that this DECLARATION RE: ELECTRONIC FILING is to be submitted to the Clerk once all schedules have been filed but, in any event, no later than 15 days following the date the petition was 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. 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. 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:

_____________________________ Signature of Debtor _____________________________ Signature of Joint Debtor Dated: _______________________

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: __________ _________________________________ Address _________________________________ Phone No.