UNITED STATES BANKRUPTCY COURT DISTRICT OF NEW HAMPSHIRE In re: __________________________________________, Debtor Bk. No. ____-_________-____ Chapter ____ DECLARATION REGARDING ELECTRONIC FILING FOR DOCUMENTS OTHER THAN PETITIONS, SCHEDULES AND AMENDMENTS TO SCHEDULES PART 1 - Declaration of Declarant: I,_____________________________________________________, the undersigned declarant, hereby declares under penalty of perjury that I have signed the document identified below and that the information contained in the document identified below that is to be electronically filed is true and correct, to the best of my knowledge and belief. I understand that this DECLARATION REGARDING ELECTRONIC FILING is to be submitted to the clerk after the document identified below has been filed electronically but, in no event, no later than seven (7) days after the document has been filed. I acknowledge receipt of a copy of the document that is to be electronically filed. PART 2 - Identification of Document: _____________________________________[Name of document] dated ________________, consisting of _______ pages. I understand and agree that failure to file the signed original of this DECLARATION is grounds for the Court to strike the document identified above from the record in this proceeding. Date: ___________________ _______________________________________ Name _______________________________________ Title (Insert acknowledgment if required) LBF 5005-4B (Eff. 12/1/09) American LegalNet, Inc. www.FormsWorkFlow.com Part 3 - Declaration of Attorney: I declare that, to the best of my knowledge, information and belief, formed after an inquiry reasonable under the circumstances, that the document identified above is not being presented for any improper purpose; that the allegations and other factual contentions have, or will have, evidentiary support; and that the denials of factual contentions are warranted. I further certify that the declarant signed this Declaration and authorized me to electronically file the document identified above, that I gave the declarant a copy of the document identified above that is to be electronically filed, and that the document identified in the attached Notice of Electronic Filing from the CM/ECF system is the document identified above. Date: ___________________ _______________________________________ Signature _______________________________________ Print Name Address________________________________ _______________________________________ Tel. No.________________________________ NOTE: You must attach the Notice of Electronic Filing as an exhibit. (FILE ORIGINAL WITH COURT. DO NOT FILE ELECTRONICALLY.) LBF 5005-4B (Eff. 12/1/09) American LegalNet, Inc. www.FormsWorkFlow.com