Free B280 - DISCLOSURE OF COMPENSATIONOF BANKRUPTCY PETITIONPREPARER - California

Form B280 (10/05)

USBC, EDCA

UNITED STATES BANKRUPTCY COURT EASTERN DISTRICT OF CALIFORNIA
In re Case No.:

Debtor.

DISCLOSURE OF COMPENSATION OF BANKRUPTCY PETITION PREPARER1

1. Under 11 U.S.C. § 110(h), I declare under penalty of perjury that I am not an attorney or employee of an attorney, that I prepared or caused to be prepared one or more documents for filing by the above-named debtor(s) in connection with this bankruptcy case, and that compensation paid to me within one year before the filing of the bankruptcy petition, or agreed to be paid to me, for services rendered on behalf of the debtor(s) in contemplation of or in connection with the bankruptcy case is as follows: For document preparation services, I have agreed to accept . . . . . . . . . . . . . . . . . . . . Prior to the filing of this statement I have received . . . . . . . . . . . . . . . . . . . . . . . . . . . . Balance Due . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2. I have prepared or caused to be prepared the following documents (itemize): $___________________ $___________________ $___________________

and provided the following services (itemize):

3. The source of the compensation paid to me was: Debtor Other (specify):

4. The source of compensation to be paid to me is: Debtor Other (specify):

5. The foregoing is a complete statement of any agreement or arrangement for payment to me for preparation of the petition filed by the debtor(s) in this bankruptcy case. 6. To my knowledge no other person has prepared for compensation a document for filing in connection with this bankruptcy case except as listed below: NAME SOCIAL SECURITY NUMBER
(Required by 11 U.S.C. § 110(c).)

1

This document must be filed with the debtor's bankruptcy petition if a bankruptcy petition preparer prepares the petition. 11 U.S.C. § 110(h)(2).

Form B280 (10/05)

USBC, EDCA

X__________________________________ Signature of Bankruptcy Petition Preparer

___________________________________________ Social Security No. of Bankruptcy Petition Preparer (If the bankruptcy petition preparer is not an individual, state the name, title (if any), address, and social security number of the officer, principal, responsible person or partner of the bankruptcy petition preparer. (Required under 11 U.S.C. § 110.)

______________ Date

__________________________________________________ Printed Name and Title, if any, of Bankruptcy Petition Preparer

__________________________________________________ Address __________________________________________________ __________________________________________________

A bankruptcy petition preparer's failure to comply with the provisions of title 11 and the Federal Rules of Bankruptcy Procedure may result in fines or imprisonment or both. 11 U.S.C. § 110; 18 U.S.C. § 156.