Disclosure of Compensation - (Rev. 12/03) 2003 USBC, Central District of California UNITED STATES BANKRUPTCY COURT CENTRAL DISTRICT OF CALIFORNIA Attorney or Party Name, Address, and Telephone Number FOR COURT USE ONLY In re CASE NO.: CHAPTER: Debtor Address: Debtor. DISCLOSURE OF COMPENSATION OF BANKRUPTCY PETITION PREPARER 1. Under 11 U.S.C. § 110(h), I declare under penalty of perjury that I am not an attorney or employee of an attorney, that I prepared or caused to be prepared one or more documents for filing by the above-named debtor(s) in connection with this bankruptcy case, and that compensation paid to me within one year before the filing of the bankruptcy petition, or agreed to be paid to me, for services rendered on behalf of the debtor(s) in contemplation of or in connection with the bankruptcy case is as follows: For document preparations services, I have agreed to accept . . . . . . . . . . . . . . . . . . . $ Prior to the filing of this statement I have received . . . . . . . . . . . . . . . . . . . . . . . . . . . . $ Balance Due . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . $ 2. I have prepared or caused to be prepared the following documents (itemize): and provided the following services (itemize): 3. The source of the compensation paid to me was: G debtor G Other (specify): 4. The source of compensation to be paid to me is: G debtor G Other (specify): 5. The foregoing is a complete statement of any agreement or arrangement for payment to me for preparation of the petition filed by the debtor(s) in this bankruptcy case. 6. To my knowledge no other person has prepared for compensation a document for filing in connection with this bankruptcy case except as listed below: Name Complete Social Security Number Disclosure of Compensation - Page 2 - (Rev. 12/03) 2003 USBC, Central District of California In re Case No.: Debtor. (If known) DECLARATION OF BANKRUPTCY PETITION PREPARER I declare under penalty of perjury that the foregoing is true and correct to the best of my knowledge, information, and belief. Signature Complete Social Security Number Date Name (Print): Address: A bankruptcy petition preparer’s failure to comply with the provisions of title 11 and the Federal Rules of Bankruptcy Procedure may result in fines or imprisonment or both. 11 U.S.C. § 110; 18 U.S.C. § 156.