UNITED STATES BANKRUPTCY COURT CENTRAL DISTRICT OF CALIFORNIA Attorney or Party Name, Address, Telephone & FAX Nos., State Bar No. & Email Address DIVISION CASE NO.: CHAPTER: ADVERSARY NO.: (if applicable) Attorney for: In re: ELECTRONIC FILING DECLARATION (INDIVIDUAL) [LBR 1002-1(f)] Debtor(s). Petition, statement of affairs, schedules or lists Date filed: Amendments to the petition statements of affairs, schedules or lists Date filed: Other (specify): _______________________________________________ Date filed: PART I ­ DECLARATION OF DEBTOR(S) OR OTHER PARTY I (We), the undersigned Debtor(s) or other party on whose behalf the above-referenced document is being filed (Signing Party), declare under penalty of perjury that: (1) I have read and understand the above-referenced document being filed electronically (Filed Document); (2) the information provided in the Filed Document is true, correct and complete; (3) the "/s/," followed by my name, on the signature line(s) for the Signing Party in the Filed Document serves as my signature and denotes the making of such declarations, requests, statements, verifications and certifications to the same extent and effect as my actual signature on such signature line(s); (4) I have actually signed a true and correct printed copy of the Filed Document in such places and provided the executed printed copy of the Filed Document to my attorney; and (5) I have authorized my attorney to file the electronic version of the Filed Document and this Declaration with the United States Bankruptcy Court for the Central District of California. If the Filed Document is a petition, I further declare under penalty of perjury that I have completed and signed a Statement About Your Social Security Numbers (Official Form 121) and provided the executed original to my attorney. Date: _________________________________________________________ Signature (handwritten) of Debtor or signing party _________________________________________________________ Printed name of signing party _________________________________________________________ Signature (handwritten) of Debtor 2 (Joint Debtor)(if applicable) _________________________________________________________ Printed name of Debtor 2, if applicable Date: PART II ­ DECLARATION OF ATTORNEY FOR SIGNING PARTY I, the undersigned attorney for the Signing Party, declare under penalty of perjury that: (1) the "/s/," followed by my name, on the signature lines for the attorney for the Signing Party in the Filed Document serves as my signature and denotes the making of such declarations, requests, statements, verifications and certifications to the same extent and effect as my actual signature on such signature lines; (2) the Signing Party signed Part 1 - Declaration of Debtor(s) or Other Party of this Declaration before I electronically submitted the Filed Document for filing with the United States Bankruptcy Court for the Central District of California; (3) I have actually signed a true and correct printed copy of the Filed Document in the locations that are indicated by "/s/," followed by my name, and have obtained the signature(s) of the Signing Party in the locations that are indicated by "/s/," followed by the Signing Party's name, on the true and correct printed copy of the Filed Document; (4) I shall maintain the executed originals of this Declaration and the Filed Document for a period of five years after the closing of the case in which they are filed; and (5) I shall make the executed originals of this Declaration and the Filed Document available for review upon request of the court or other parties. If the Filed Document is a petition, I further declare under penalty of perjury that: (1) the Signing Party completed and signed the Statement About Your Social Security Numbers (Official Form 121) before I electronically submitted the Filed Document for filing with the United States Bankruptcy Court for the Central District of California; (2) I shall maintain the executed original of the Statement About Your Social Security Numbers (Official Form 121) for a period of five years after the closing of the case in which they are filed; and (3) I shall make the executed original of the Statement About Your Social Security Numbers (Official Form 121) available for review upon request of the court. Date: ________________________________________________ Signature (handwritten) of attorney for Signing Party ________________________________________________ Printed Name of attorney for Signing Party This form is mandatory. It has been approved for use by the United States Bankruptcy Court for the Central District of California. December 2015 F 1002-1.DEC.ELEC.FILING.INDIVIDUAL