UNITED STATES BANKRUPTCY COURT WESTERN DISTRICT OF WASHINGTON In re: Case No. Name of Debtor(s) 1. (If Known) Pursuant to 11 U.S.C. ' 329(a) and Bankruptcy Rule 2016(b), I certify that I am the attorney for the above-named debtor(s) and that compensation paid to me within one year before the filing of the petition in bankruptcy, or agreed to be paid to me, for services rendered or to be rendered on behalf of the debtor(s) in contemplation of or in connection with the bankruptcy case is as follow: For legal services, I have agreed to accept . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Prior to the filing of this statement I have received. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . $_____________ Balance Due. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2. $_____________ $_____________ The source of the compensation paid to me was: q 3. Debtor q Other (specify) The source of compensation to be paid to me is: q 5. q I have not agreed to share the above-disclosed compensation with any other person unless they are members and associates of my law firm. q 4. Debtor q Other (specify) I have agreed to share the above-disclosed compensation with a person or persons who are not members or associates of my law firm. A copy of the agreement, together with a list of the names of the people sharing in the compensation, is attached. In return for the above-disclosed fee, I have agreed to render legal service for all aspects of the bankruptcy case, including: a. b. Preparation and filing of any petition, schedules, statement of affairs and plan which may be required; c. Representation of the debtor at the meeting of creditors and confirmation hearing, and any adjourned hearings thereof; d. Representation of the debtor in adversary proceedings and other contested bankruptcy matters; e. 6. Analysis of the debtor=s financial situation, and rendering advice to the debtor in determining whether to file a petition in bankruptcy; [Other provisions as needed]. By agreement with the debtor(s), the above-disclosed fee does not include the following services CERTIFICATION I certify that the foregoing is a complete statement of any agreement or arrangement for payment to me for representation of the debtor(s) in this bankruptcy proceeding. __________________________________ Date __________________________________________ Signature of Attorney __________________________________________ Name of Law Firm 2000 © American LegalNet, Inc.