FLNB Local Form 1 (05/07) (05/07) United States Bankruptcy Court Northern District of Florida IN RE: Case No. Chapter Debtor(s) DEBTOR'S STATEMENT OF ASSISTANCE RECEIVED IN CONNECTION WITH THE FILING OF THIS CASE I DID NOT RECEIVE ANY ASSISTANCE IN PREPARING THIS CASE FOR FILING. I DID RECEIVE ASSISTANCE IN PREPARING THIS CASE FOR FILING. 1. The person or firm that assisted is: Name Address City Telephone 2. I paid the sum of $ 3. I still owe the sum of $ 4. I agreed to turn over or give a security interest in the following property: ST: Zip: , the Debtor(s), do hereby declare under I (we) penalty of perjury , that the statements made are true and correct. Executed this day of (Day) (Month) , 20 (Year) . Signature of Debtor Signature of Joint Debtor Print Form Reset Form American LegalNet, Inc. www.FormsWorkFlow.com