Form 3A (11/11) United States Bankruptcy Court Northern District Of Georgia In re _______________________________________, Debtor Case No. ___________________ Chapter ____________ APPLICATION TO PAY FILING FEE IN INSTALLMENTS FOR INDIVIDUALS IN CHAPTER 7 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 for permission to pay the filing fee amounting to $ 306.00 in installments. 2. I am unable to pay the filing fee except in installments. 3. I [_] have/ [_]have not/paid money or transferred property to an attorney or bankruptcy petition preparer for services in connection with this case. 4. I will not make any payment or transfer any property for services in connection with this case until the filing fee is paid in full. 5. I accept the following terms for the payment of the Filing Fee. * * * * 6. First Installment of at least $75.00 with the filing of the Petition. Second Installment in an amount not less than one-third of the unpaid balance of the filing fee shall be due and payable on or before 40 days from the Petition date. Third Installment in an amount not less than one-third of the unpaid balance of the filing fee shall be due and payable on or before 80 days from the Petition date. Final Installment shall equal the remaining unpaid balance of the filing fee and shall be due and payable on or before 120 days from the Petition date. I understand that if I fail to pay any installment when due, my bankruptcy case may be dismissed and I may not receive a discharge of my debts. ___________________________________________ Signature of Attorney Date __________________________________________________________ Signature of Debtor Date (In a joint case, both spouses must sign.) ___________________________________________ Name of Attorney __________________________________________________________ Signature of Joint Debtor (if any) Date ------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------DECLARATION AND SIGNATURE OF NON-ATTORNEY BANKRUPTCY 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. ________________________________ ________________________________ 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 American LegalNet, Inc. both. 11 U.S.C. § 110; 18 U.S.C. § 156. www.FormsWorkFlow.com