UNITED STATES BANKRUPTCY COURT SOUTHERN DISTRICT OF FLORIDA www.flsb.uscourts.gov In re: Case No. Chapter 13 Debtor / APPLICATION FOR COMPENSATION FOR PROFESSIONAL SERVICES OR REIMBURSEMENT OF EXPENSES BY ATTORNEY FOR CHAPTER 13 DEBTOR Applicant, , was retained by the debtor to serve in this bankruptcy case as attorney for debtor. A copy of the retainer agreement is attached as Exhibit "A". Pursuant to Local Rule 2016-1(B)(2) and the "Chapter 13 Fee Guidelines", applicant hereby requests the court to approve compensation and reimbursement of expenses as follows: Total Fees Requested: Total Expenses to be Reimbursed: Amount Received To-Date: (exclusive of filing fees) $ $ $ $ monthly Amount to be Paid through Plan: 1. The amount requested, if allowed, will be paid in full after payments under the plan. 2. A detailed itemization of the services rendered to date and corresponding time entries is attached as Exhibit "B". 3. Applicant estimates that an additional hours will be required to be expended in providing legal services on behalf of the debtor(s) described below: . LF-69 (rev. 12/01/09) Page 1 of 2 American LegalNet, Inc. www.FormsWorkFlow.com 4. The following is a short statement of any unusual, troublesome or unique aspects of this case which resulted in or will result in more than the usual amount of time being expended and more than the usual amount of costs being incurred: . 5. The source of compensation previously paid to applicant was . 6. Applicant has not shared or agreed to share any compensation received in connection with the bankruptcy case with any person or entity other than a member or regular associate of applicant's firm. (If such a sharing arrangement exists, it should be disclosed in this paragraph.) DATED: Applicant's Signature Name Address Phone c: Debtor Chapter 13 Trustee LF-69 (rev. 12/01/09) Page 2 of 2 American LegalNet, Inc. www.FormsWorkFlow.com