UNITED STATES BANKRUPTCY COURT NORTHERN DISTRICT OF CALIFORNIA In Re: ) ) ) ) Bankruptcy Case No.
STATEMENT RE PAYMENT ADVICES 9 Attached are copies of all payment advices or other evidence of payment that I/we received from my/our employer(s) within the 60 days before the filing of this bankruptcy case. I/we have blocked out all but the last four digits of my/our social security number(s) wherever they appear on the attached copies. I/We received no payment advices or other evidence of payment from my/our employer(s) within the 60 days before the filing of this bankruptcy case.
I/we declare under penalty of perjury that the above statement is true and correct to the best of my/our knowledge, information, and belief. Date:_______ Date:_______ _________________________________ Signature of Debtor _________________________________ Signature of Joint Debtor _________________________________ Signature of Attorney
DECLARATION AND SIGNATURE OF NON-ATTORNEY BANKRUPTCY PETITION PREPARER (See 11 U.S.C. § 110) I declare under penalty of perjury that: (1) I am a bankruptcy petition preparer as defined in 11 U.S.C. § 110; (2) I prepared this document for compensation and have provided the debtor with a copy of this document and the notices and information required under 11 U.S.C. §§ 110(b), 110(h) and 342(b); and (3) if rules or guidelines have been promulgated pursuant to 11 U.S.C. § 110(h) setting a maximum fee for services chargeable by bankruptcy petition preparers, I have given the debtor notice of the maximum amount before preparing any document for filing for a debtor or accepting any fee from the debtor, as required by that section. _____________________________________________________ _________________________ Printed or Typed Name of Bankruptcy Petition Preparer Social Security No. (Required by 11 U.S.C. § 110) 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 who signs this document. _____________________________________ ______________________________________ Address X_________________________________________________ Signature of Bankruptcy Petition Preparer ________________________ Date
Names and Social Security numbers of all other individuals who prepared or assisted in preparing this document, unless the bankruptcy petition preparer is not an individual: If more than one person prepared this document, attach additional signed sheets conforming to the appropriate Official Form for each person. 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.