IN THE UNITED STATES BANKRUPTCY COURT FOR THE SOUTHERN DISTRICT OF ALABAMA IN RE: CHAPTER 13 , Case No. Debtor(s). APPLICATION FOR EMPLOYMENT OF ATTORNEY AS A PROFESSIONAL PERSON FOR A SPECIFIC PURPOSE IN A CHAPTER 13 CASE AND VERIFIED STATEMENT OF DISINTERESTEDNESS Debtor(s) hereby applies to employ an attorney as a professional person pursuant to 11 U.S.C. 247247 327(e) and 328(a) and Bankruptcy Rule 2014 to prosecute a cause of action or suit on his or their behalf. In support of this application, debtor(s) provides the following information: 1. Name of attorney (and firm, if applicable) proposed to be retained: . 2. Description of cause of action or suit: . 3. The proposed fee is a contingent fee of (describe) plus reimbursement of out-of-pocket expenses. A copy of the fee agreement is attached. If there is no recovery, the debtor(s) and/or bankruptcy estate will not be responsible for attorney222s fees or reimbursement of expenses. 4. Any other attorneys (other than members of the same firm) with whom the proposed attorney has agreed to share compensation: . 5. No money has been paid to the proposed attorney or firm in connection with this matter prior to the filing of this application. The proposed attorney has not agreed to share American LegalNet, Inc. www.FormsWorkFlow.com 2 compensation with other attorneys in this matter except as set out above and understands that he or she cannot share any compensation with attorneys other than members of his or her firm unless they are also approved by this Court. 6. Upon settlement or completion of the cause of action, the proposed attorney will apply to the Court for approval of any settlement recovered on behalf of the debtor(s) and/or the estate and for approval of fees and expenses pursuant to 11 U.S.C. 247 328(a) and Bankruptcy Rule 2016. Attorney for Debtor(s) ADDRESS PHONE AND FAX EMAIL Verified Statement of Disinterestedness I declare under penalty of perjury the following: I have read the statements contained in the preceding application to employ, and they are true and correct. I do not represent or hold any interest adverse to the debtor(s) or the estate with respect to the matters upon which I seek to be employed. I have no connection with the Chapter 13 trustee, any creditors in this case, the bankruptcy administrator, the debtor(s), or their respective attorneys, or any other party-in-interest, other than the representation of the debtor(s) in the claim or lawsuit relating to which I am applying for employment as a professional person. Date: Attorney American LegalNet, Inc. www.FormsWorkFlow.com 3 CERTIFICATE OF SERVICE I certify that I have served a copy of the foregoing Application on the parties listed below by placing same in the United States mail, postage prepaid and properly addressed, this day of , 20. Daniel B. O222Brien Chapter 13 Trustee One St. Louis Center, 2nd Floor Mobile, AL 36602 American LegalNet, Inc. www.FormsWorkFlow.com