Statement Regarding Assistance of Non-Attorney - Local Bankruptcy Rule 1002-1 (Rev. 12/03) 2003 USBC, Central District of California UNITED STATES BANKRUPTCY COURT CENTRAL DISTRICT OF CALIFORNIA In re Case No.: Chapter: STATEMENT REGARDING ASSISTANCE OF NON-ATTORNEY WITH RESPECT TO THE FILING OF BANKRUPTCY CASE THE DEBTOR/JOINT DEBTOR DOES HEREBY STATE AND REPRESENT: G I received assistance from a non-attorney in connection with the filing of my bankruptcy case. 1. I paid the sum of $ 2. I still owe the sum of $ 3. I agreed to turn over or give a security interest in the following property: 4. The name of the person or the name of the firm that assisted me was: Name: Address: Telephone: G I did not receive assistance from a non-attorney in connection with the filing of my bankruptcy case. I declare under penalty of perjury that the foregoing is true and correct. , California. Executed at Executed on: Date Debtor Joint Debtor