UNITED STATES BANKRUPTCY COURT NORTHERN DISTRICT OF GEORGIA ____________ DIVISION In re Case No. _________ ________________________, Debtor. Chapter _________ APPLICATION TO PAY FILING FEE IN INSTALLMENTS FOR INDIVIDUALS IN CHAPTER 11 OR 13 CASES 1. In accordance with Fed. R. Bankr. P. 1006 and General Order No. 4-2005 (Bankr. N.D. Ga., October 5, 2005), I apply to pay the filing fee amounting to $_______ in no more than three (3) installments. 2. I certify that I am unable to pay the filing fee except in installments. 3. I further certify that I will neither make any payment nor transfer any property for services in connection with this case until the filing fee is paid in full. 4. I accept the following terms for the payment of the filing fee: ! First Installment of $_______, with the filing of the petition. ! Second Installment of at least one-half of the unpaid balance of the filing fee in the amount of $_______, on or before 30 days from the date the bankruptcy petition was filed. ! Final Installment of the remaining unpaid balance of the filing fee in the amount of $_______, on or before 60 days from the date the bankruptcy petition was filed. 5. I understand that if I fail to pay any fee installment when due my bankruptcy case will be dismissed. _____________________________ Signature of Attorney Date _________________________________ Signature of Debtor Date (In a joint case, both Debtors must sign) _____________________________ Name of Attorney _________________________________ Signature of Joint Debtor Date 1 American LegalNet, Inc. www.USCourtForms.com DECLA RATION AND SIGN ATUR E OF NO N-ATTO RNEY BANK RUPTC Y PETITION (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 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 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. ________________________________ ________________________________ Add ress 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 p etition prepa rer’s failure to com ply with the p rovisions 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. 2 American LegalNet, Inc. www.USCourtForms.com