UNITED STATES BANKRUPTCY COURT FOR THE NORTHERN DISTRICT OF FLORIDA DIVISION CASE NO.: CHAPTER 13 IN RE: Debtor(s) ___________________/ ANNUAL STATEMENT (Pursuant to 11 U.S.C. '521(f) and Standing Order of this Court) COMES NOW Debtor(s), ____________________________________, by and through the undersigned attorney(s), and files this Annual Statement in accordance with 11 U.S.C. '521(f) and Standing Order of this Court, and hereby states as follows: 1. The income and expenditures of the Debtor(s), during the tax year most recently concluded before this Annual Statement is filed, are detailed on the attached Schedule I and J worksheets. The method of calculation of the Debtor(s)= monthly income and expenditures is detailed on the attached Schedules I and J worksheets. The attached schedule worksheets are not intended to amend previously filed schedules. 2. The Debtor(s)= monthly income is disclosed as follows: A. The amount and source of income of the Debtor(s) are as follows: B. The identity of any person responsible with the Debtor(s) for the support of any dependent of the Debtor(s): American LegalNet, Inc. www.FormsWorkflow.com C. The identity of any person who contributed, and the amount contributed, to the household in which the Debtor(s) resides: 3. The Debtor(s) will ____ or will not _____ be filing a Motion to Modify Chapter 13 Plan due to changes in income and expenses as shown on Schedules I and J worksheets. 4. The Debtor(s) has filed the Annual Statement as required by 11 U.S.C. '521(f) and Standing Order of this Court and has complied with related provisions for the submission of tax returns to the Chapter 13 Trustee. The Debtor(s)= attorney is now eligible for disbursement of $75.00, and the Trustee is authorized to disburse said funds, if available. RESPECTFULLY SUBMITTED. ________________________________ Attorney for the Debtor(s) CERTIFICATE OF SERVICE I HEREBY CERTIFY that a true and correct copy of the foregoing has been furnished by electronic filing or first class mail to: on the same date as reflected on the Court=s docket as the electronic filing date for this document. ____________________________________ Attorney for Debtor(s) American LegalNet, Inc. www.FormsWorkflow.com