Ver. 2/1/11 United States Bankruptcy Court Northern District of Florida Application for Limited Use Access to Electronic Case Filing System Name: Street Address: City _______________________________ State _________ Zip _____________________ Phone: Fax E-mail: Do you file electronically in other U.S. Courts (Bankruptcy or District)? Yes No If yes, which courts? ___________________________________________________________________ Bar I.D. (If applicable) State of 1. I affirm that I am authorized to prepare and file documents such as Proofs of Claim, Reaffirmation Agreements, Requests for Notice, and other creditor pleadings on behalf of . 2. I understand that use of my Limited Use password to file a document in the record of a bankruptcy case or proceeding will constitute my signature upon and my signing of any declarations, verifications, proofs of claim, applications to withdraw unclaimed funds, requests for notice, assignments of claims, reaffirmation agreements, or proofs of claim or other papers involving a child support creditor, or other papers or documents filed by use of the password obtained pursuant to this Application (my password), for all purposes authorized and required by law, including , without limitation, the United States Code, Federal Rules of Civil Procedure, Federal Rules of Bankruptcy Procedure, Federal Rules of Criminal Procedure and any applicable non bankruptcy law. 3. I understand that it is my responsibility to maintain in my records all documents bearing my original signature that are filed using my password, and all documents bearing the original signature of any signer on whose behalf I file the documents using my password, for a period of four years after the case or proceeding in which the papers are filed has been closed. 4. I understand that it is my responsibility to protect and secure the confidentiality of my password. If I believe that my password has been compromised, it is my responsibility to notify the court in writing, immediately. 5. I understand that it is my responsibility to notify the court, immediately of any change in my address, telephone number, fax number, or e-mail address. 6. I agree to adhere to court guidelines for the Electronic Case Filing System. I understand that it is my responsibility to learn and use any and all updates to the electronic case filing procedures. Applicant’s Signature ___________________________________ Date __________________________ Title: _________________________________________ Mail to: U. S. Bankruptcy Court Attn: Ne'Shoni Foulks 110 E. Park Ave., Suite 100 Tallahassee, FL 23201 NeShoni_Foulks@flnb.uscourts.gov American LegalNet, Inc. www.FormsWorkFlow.com