UNITED STATES BANKRUPTCY COURT SOUTHERN DISTRICT OF FLORIDA www.flsb.uscourts.gov In re: Case No. Chapter Debtor / DECLARATION REGARDING PAYMENT ADVICES Debtor: Copies of all payment advices, pay stubs or other evidence of payment received by the debtor from any employer within 60 days prior to the filing of the bankruptcy petition are attached. (Note: If you worked some, but not all of the 60 days prior, attach copies of any and all received and provide explanation that you didn't work the full 60 days. ______________________________________________________________________) Copies of all payment advices are not attached because the debtor had no income from any employer during the 60 days prior to filing the bankruptcy petition. Copies of all payment advices are not attached because the debtor: receives disability payments is unemployed and does not receive unemployment compensation receives Social Security payments receives a pension does not work outside the home is self employed and does not receive payment advices None of the statements above apply, however, the debtor is unable to timely provide some or all copies of payment advices or other evidence of payment received Explain:_________________________________________________________________ Joint Debtor (if applicable): Copies of payment advices, pay stubs or other evidence of payment received by the joint debtor from any employer within 60 days prior to the filing of the bankruptcy petition are attached. (Note: If you worked some, but not all of the 60 days prior, attach copies of any and all received and provide explanation that you didn't work the full 60 days. ______________________________________________________________________) Copies of payment advices are not attached because the joint debtor had no income from any employer during the 60 days prior to filing the bankruptcy petition. LF-10 (06/02/08) Page 1 of 2 American LegalNet, Inc. www.FormsWorkflow.com Copies of payment advices are not attached because the joint debtor: receives disability payments is unemployed and does not receive unemployment compensation receives Social Security payments receives a pension does not work outside the home is self employed and does not receive payment advices None of the statements above apply, however, the joint debtor is unable to timely provide some or all copies of payment advices or other evidence of payment received Explain: NOTE: When submitting copies of evidence of payment such as pay stubs or payment advices, it is your responsibility to redact (blackout) any social security numbers, names of minor children, dates of birth or financial account numbers before attaching for filing with the court. Date: Signature of Attorney or Debtor Date: Signature of Attorney or Joint Debtor LF-10 (06/02/08) Page 2 of 2 American LegalNet, Inc. www.FormsWorkflow.com