Revised September 2012 PROFESSIONAL FEE STATEMENT (Page 1 of 2) USTR16-6.0 Attorney or Professional Name, Address, Telephone and FAX UNITED STATES BANKRUPTCY COURT CENTRAL DISTRICT OF CALIFORNIA In re: Debtor Chapter 11 Case Number Professional Fee Statement Number: Month of: , 20 1. Name of Professional: 2. Date of entry of order approving employment of the professional: 3. Total amount of pre-petition payments received by the professional: $ 4. Less: Total amount of pre-petition services rendered and expenses: - 5. Balance of funds remaining on date of filing of petition: $ 6. Less: Total amount of all services rendered per prior fee statements: (Line 6 is not used when filing Statement Number 1). - 7. Less: Total amount of services and expenses this reporting period: - 8. Balance of funds remaining for next reporting period: $ DETAILED DOCUMENTATION SUPPORTING THE PROFESSIONAL FEES EARNED AND THE EXPENSES INCURRED DURING THIS REPORTING PERIOD HAS BEEN SERVED ON THE UNITED STATES TRUSTEE. A COPY OF THE DETAILED DOCUMENTATION WILL BE PROVIDED BY THE PROFESSIONAL TO ANY PARTY UPON REQUEST. FEES AND COSTS WILL BE WITHDRAWN FROM THE TRUST ACCOUNT IN THE AMOUNT STATED IN ITEM 7 ABOVE UNLESS AN OBJECTION IS FILED WITH THE CLERK OF THE COURT AND SERVED ON THE PROFESSIONAL NAMED ABOVE WITHIN 10 DAYS FROM THE DATE OF SERVICE OF THIS STATEMENT. 9. Total number of pages attached hereto: The above is a true and correct statement of fees earned and expenses incurred during the indicated reporting period. Dated: Type Name of Professional Signature of Professional Type Name of Attorney for Professional (if applicable) Signature of Attorney for Professional (if applicable) American LegalNet, Inc. www.FormsWorkFlow.com Revised September 2012 PROFESSIONAL FEE STATEMENT (Page 2 of 2) USTR16-6.0 In re: (Short Title) Debtor Chapter 11 Case Number: PROOF OF SERVICE BY MAIL STATE OF CALIFORNIA COUNTY OF I am employed in the county of , State of California, in the office of a member of the bar of this Court at whose direction the service was made; I am over the age of 18 and not a party to the within action; and my business address is as follows: On , I served the foregoing PROFESSIONAL FEE STATEMENT on the interested parties at their last known addresses in this action by placing a true and correct copy thereof in a sealed envelope with first class postage thereon fully prepaid in the United States Mail at , California, addressed as follows: I declare under penalty of perjury that the foregoing is true and correct. Dated: Print Name Signature American LegalNet, Inc. www.FormsWorkFlow.com