CSD 4170 [12/01/18] Name, Address, Telephone No. & I.D. No. UNITED STATES BANKRUPTCY COURT SOUTHERN DISTRICT OF CALIFORNIA 325 West F Street, San Diego, California 92101-6991 In Re Debtor. BANKRUPTCY NO. Plaintiff(s) ADVERSARY NO. v. Defendant(s) DECLARATION OF INMATE FILING I am an inmate confined in an institution. Today, , I am depositing (Insert date) the (Insert title of document; fo r example, 223notice of appeal224) in this case in the institution222s internal mail system. First - class postage is being prepaid either by me or by the institution on my behalf. I declare under penalty of perjury that the foregoing is true and c orrect (see 28 U.S.C. 247 1746; 18 U.S.C. 247 1621). Type your name here Sign your name here Signed on (Insert date) [Note to inmate filers: If you r institution has a system designed for le gal mail, you must use that system in order t o receive the timing benefit of Fed. R. Bankr. P. 8002 (c)(1) or Fed. R. Bankr. P. 80 1 1(a)(2)(C).] CSD 4170 American LegalNet, Inc. www.FormsWorkFlow.com