B19 (Official Form 19) (12/07)
United States Bankruptcy Court
_____ District Of _______________
In re _______________________________, Debtor Case No. _________________ Chapter ______________
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 the accompanying document(s) listed below for compensation and have provided the debtor with a copy of the document(s) and the attached notice as required by 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. Accompanying documents: ___________________________________ ___________________________________ ___________________________________ ___________________________________ ___________________________________ Printed or Typed Name and Title, if any, of Bankruptcy Petition Preparer: Social-Security No. of Bankruptcy Petition Preparer (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.
B19 (Official Form 19) (12/07) - Cont.
NOTICE TO DEBTOR BY NON-ATTORNEY BANKRUPTCY PETITION PREPARER [Must be filed with any document(s) prepared by a bankruptcy petition preparer.] I am a bankruptcy petition preparer. I am not an attorney and may not practice law or give legal advice. Before preparing any document for filing as defined in § 110(a)(2) of the Bankruptcy Code or accepting any fees, I am required by law to provide you with this notice concerning bankruptcy petition preparers. Under the law, § 110 of the Bankruptcy Code (11 U.S.C. § 110), I am forbidden to offer you any legal advice, including advice about any of the following: · · · · · · · · · whether to file a petition under the Bankruptcy Code (11 U.S.C. § 101 et seq.); whether commencing a case under chapter 7, 11, 12, or 13 is appropriate; whether your debts will be eliminated or discharged in a case under the Bankruptcy Code; whether you will be able to retain your home, car, or other property after commencing a case under the Bankruptcy Code; the tax consequences of a case brought under the Bankruptcy Code; the dischargeability of tax claims; whether you may or should promise to repay debts to a creditor or enter into a reaffirmation agreement with a creditor to reaffirm a debt; how to characterize the nature of your interests in property or your debts; or bankruptcy procedures and rights.
[The notice may provide additional examples of legal advice that a bankruptcy petition preparer is not authorized to give.] In addition, under 11 U.S.C. § 110(h), the Supreme Court or the Judicial Conference of the United States may promulgate rules or guidelines setting a maximum allowable fee chargeable by a bankruptcy petition preparer. As required by law, I have notified you of this maximum allowable fee, if any, before preparing any document for filing or accepting any fee from you. ____________________________________ Signature of Debtor Date [In a joint case, both spouses must sign.] _______________________________ Joint Debtor (if any) Date