UNITED STATES BANKRUPTCY COURT SOUTHERN DISTRICT OF FLORIDA www.flsb.uscourts.gov In re: Case No. Chapter Debtor / APPLICATION BY INDIVIDUAL DEBTOR TO PAY FILING FEE IN INSTALLMENTS In accordance with Bankruptcy Rule 1006 and Local Rule 1006-1, application is made for permission to pay the filing fee of $ on the following terms: $ with the filing of the petition. (Note: An initial payment of AT LEAST $50.00 must accompany the application prior to clerk’s approval of application without further review by court.) in and the balance of $ follows: Payment Two $ Payment Four $ on or before on or before installments, (in cash or cashier's check) within 120 days as ; Payment Three $ on or before I certify that I am unable to pay the above filing fee except in installments. I further certify that until the filing fee is paid in full, I will not make any additional payment or transfer any additional property to an attorney or any other person for services in connection with this case. If I am a chapter 13 debtor, I understand that upon confirmation of my plan, the unpaid balance of the filing fee must be paid in full. If I am a chapter 7 debtor, I understand my discharge will not be entered until my filing fee is paid in full and I understand that if I fail to pay any installment when due, my case will be dismissed without further notice. The proposed date of my last installment payment is not later than 120 days from the date my petition was filed. For cause shown, the court may extend the time of any installment, provided the last installment is paid not later than 180 days after filing the petition Bankruptcy Rule 1006(b)(2). Date: Date: Signature of Debtor Signature of Joint Debtor Address of Debtor Address of Joint Debtor DECLARATION AND SIGNATURE OF NON-ATTORNEY BANKRUPTCY PETITION PREPARER (See 11 U.S.C. §110) 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); (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 petition preparers, I have given the debtor notice of the maximum LF-3 (rev. 11/01/11) Page 1 of 2 American LegalNet, Inc. www.FormsWorkFlow.com amount before preparing any document for filing for a debtor or accepting any fee from the debtor, as required under that section; and (4) I will not accept any additional money or other property from the debtor before the filing fee is paid in full. __________________________________________________________ Printed or Typed Name and Title, if any, of Bankruptcy Petition Preparer Telephone Number __________________________________________ Social Security No. (Required by 11 U.S.C. §110.) If the bankruptcy petition preparer is not an individual, state the name, title (if any), address, and social security number of the officer, principal, responsible person, or partner who signs the document. ________________________________ ________________________________ Address x__________________________________________________ Signature of Bankruptcy Petition Preparer _____________________ Date Names and Social Security numbers of all other individuals who prepared or assisted in preparing this document, unless the bankruptcy petition preparer is not an individual: If more than one person prepared this document, attach additional signed sheets conforming to the appropriate Official Form for each person. 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. LF-3 (rev. 11/01/11) Page 2 of 2 American LegalNet, Inc. www.FormsWorkFlow.com