Attorney or Party Name, Address, Telephone & FAX Numbers, and California State Bar Number FOR COURT USE ONLY Attorney for UNITED STATES BANKRUPTCY COURT CENTRAL DISTRICT OF CALIFORNIA In re: CHAPTER _______ CASE NUMBER Debtor. (No Hearing Required) STATEMENT OF DISINTERESTEDNESS FOR EMPLOYMENT OF PROFESSIONAL PERSON UNDER F.R.B.P. 2014 (File with Application for Employment) 1. Name, address and telephone number of the professional (“the Professional”) submitting this Statement: 2. The services to be rendered by the Professional in this case are (specify): 3. The terms and source of the proposed compensation and reimbursement of the Professional are (specify): 4. The nature and terms of retainer (i.e., nonrefundable versus an advance against fees) held by the Professional are (specify): This form is optional. It has been approved for use by the United States Bankruptcy Court for the Central District of California. January 2009 F 2014-1 Statement of Disinterestedness for Employment of Professional Person - Page 2 In re F 2014-1 CHAPTER _______ Debtor. CASE NUMBER 5. The investigation of disinterestedness made by the Professional prior to submitting this Statement consisted of (specify): 6. The following is a complete description of all of the Professional’s connections with the debtor, principals of the debtor, insiders, the debtor’s creditors, any other party or parties in interest, and their respective attorneys and accountants, or any person employed in the Office of the United States Trustee (specify, attaching extra pages as necessary): 7. The Professional is not a creditor, an equity security holder or an insider of the debtor, except as follows (specify, attaching extra pages as necessary): 8. The Professional is not and was not an investment banker for any outstanding security of the debtor. 9. The Professional has not been within three (3) years before the date of the filing of the petition herein, an investment banker for a security of the debtor, or an attorney for such an investment banker in connection with the offer, sale or issuance of any security of the debtor. 10. The Professional is not and was not, within two (2) years before the date of the filing of the petition herein, a director, officer or employee of the debtor or of any investment banker for any security of the debtor. 11. The Professional neither holds nor represents any interest materially adverse to the interest of the estate or of any class of creditors or equity security holders, by reason of any direct or indirect relationship to, connection with, or interest in, the debtor or an investment banker for any security of the debtor, or for any other reason, except as follows (specify, attaching extra pages as necessary): 12. Name, address and telephone number of the person signing this Statement on behalf of the Professional and the relationship of such person to the Professional (specify): 13. The Professional is not a relative or employee of the United States Trustee or a Bankruptcy Judge, except as follows (specify, attaching extra pages as necessary): 14. Total number of attached pages of supporting documentation: _______ 15. After conducting or supervising the investigation described in Paragraph 5 above, I declare under penalty of perjury under the laws of the United States of America, that the foregoing is true and correct except that I declare that Paragraphs 6 through 11 are stated on information and belief. Executed on the _______ day of _________________________, 20______, at __________________________, California. ___________________________________ Type Name of Professional _______________________________________ Signature of Professional This form is optional. It has been approved for use by the United States Bankruptcy Court for the Central District of California. January 2009 F 2014-1 Statement of Disinterestedness for Employment of Professional Person - Page 3 In re F 2014-1 CHAPTER _______ Debtor. CASE NUMBER NOTE: When using this form to indicate service of a proposed order, DO NOT list any person or entity in Category I. Proposed orders do not generate an NEF because only orders that have been entered are placed on a CM/ECF docket. PROOF OF SERVICE OF DOCUMENT I am over the age of 18 and not a party to this bankruptcy case or adversary proceeding. My business address is: A true and correct copy of the foregoing document described as will be served or was served (a) on the judge in chambers in the form and manner required by LBR 5005-2(d), and (b) in the manner indicated below: I. TO BE SERVED BY THE COURT VIA NOTICE OF ELECTRONIC FILING (“NEF”) - Pursuant to controlling General Order(s) and Local Bankruptcy Rule(s) (“LBR”), the foregoing document will be served by the court via NEF and hyperlink to the document. On ________________________ I checked the CM/ECF docket for this bankruptcy case or adversary proceeding and determined that the following person(s) are on the Electronic Mail Notice List to receive NEF transmission at the email addressed indicated below: G Service information continued on attached page II. SERVED BY U.S. MAIL OR OVERNIGHT MAIL (indicate method for each person or entity served): On _________________________ I served the following person(s) and/or entity(ies) at the last known address(es) in this bankruptcy case or adversary proceeding by placing a true and correct copy thereof in a sealed envelope in the United States Mail, first class, postage prepaid, and/or with an overnight mail service addressed as follow. Listing the judge here constitutes a declaration that mailing to the judge will be completed no later than 24 hours after the document is filed. G Service information continued on attached page III. SERVED BY PERSONAL DELIVERY, FACSIMILE TRANSMISSION OR EMAIL (indicate method for each person or entity served): Pursuant to F.R.Civ.P. 5 and/or controlling LBR, on _______________________ I served the following person(s) and/or entity(ies) by personal delivery, or (for those who consented in writing to such service method) by facsimile transmission and/or email as follows. Listing the judge here constitutes a declaration that mailing to the judge will be completed no later than 24 hours after the document is filed. G Service information continued on attached page I declare under penalty of perjury under the laws of the United States of America that the foregoing is true and correct. _________________________________________________________ Date Type Name _____________________________________ Signature This form is optional. It has been approved for use by the United States Bankruptcy Court for the Central District of California. January 2009 F 2014-1 Statement of Disinterestedness for Employment of Professional Person - Page 4 In re F 2014-1 CHAPTER _______ Debtor. CASE NUMBER ADDITIONAL SERVICE INFORMATION (if needed): This form is optional. It has been approved for use by the United States Bankruptcy Court for the Central District of California. January 2009 F 2014-1