CSD 1004 [10/17/05] 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 BANKRUPTCY NO. Debtor. DECLARATION RE: FILING OF PETITION, SCHEDULES, & STATEMENTS ON DISKETTE The undersigned debtor(s), declare under penalty of perjury that information provided in this petition, statements, and schedules as marked below is true and correct. PART I - Select one: COMPLETE PETITION including all Schedules, Statements, and List of Creditors PETITION and List of Creditors filed with the following Schedules and Statements. (Remainder to be filed within 15 days.) CHECK ITEMS BEING FILED WITH PETITION Schedule A Schedule D Schedule G Schedule J Chapter 13 Plan, if any Schedule B Schedule E Schedule H Summary of Schedules Attorney Fee Disclosure, if any Schedule C Schedule F Schedule I Statement of Financial Affairs Statement of Intention, if any Statement of Current Monthly Income & Means Test Calculation (Individual Chapter 7 debtors only) Statement of Current Monthly Income (Individual Chapter 11 debtors only) Statement of Current Monthly Income & Calculation of Commitment Period & Disposable Income (Chapter 13) PART II - Select one: [If petitioner is an individual whose debts are primarily consumer debts and has chosen to file under chapter 7] I am aware that I may proceed under chapter 7, 11, 12 or 13 of 11 United States Code, understand the relief available under each such chapter, and choose to proceed under chapter 7. I request relief in accordance with the chapter specified in this petition. [If petitioner is a corporation or partnership] I declare under penalty of perjury that the information provided in this petition is true and correct, and that I have been authorized to file this petition on behalf of the debtor. The debtor requests relief in accordance with the chapter specified in this petition. Dated: Signed: (Debtor) (Joint Debtor) Dated: Attorney for Debtor Certification & Signature of Non-Attorney Petition Preparer I declare under penalty of perjury that: (1) I am a bankruptcy petition preparer as defined in 11 U.S.C. § 110; (2) I prepared this document for compensation and have provided the debtor with a copy of this document and the notices and information required under 11 U.S.C. § 110(b), 110(h), and 342(b); and (3) if rules or guidelines have been promulgated pursuant to 11 U.S.C. § 110(h) setting a maximum fee for services chargeable by bankruptcy petitoin preparers, I have given the debtor notice of the maximum amount before preparing any document for filing for a debtor or accepting any fee from the debtor, as required in that section. Printed Name of Bankruptcy Petition Preparer Social Security Number (Required by 11 U.S.C. §110(c).) Address Names and Social Security numbers of all other individuals who prepared or assisted in preparing this document: If more than one person prepared this document, attach additional sheets conforming to the appropriate official form for each person. X Signature of Bankruptcy Petition Preparer Date 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. CSD 1004 American LegalNet, Inc. www.USCourtForms.com