AFFIDAVIT TO ACCOMPANY PETITION FILED PRO SE. PLEASE PRINT. UNITED STATES BANKRUPTCY COURT NORTHERN DISTRICT OF GEORGIA _________ DIVISION ___________________________ CASE NO. _____________________ NAME OF DEBTOR(S) ___________________________ TELEPHONE NO. ________________ ADDRESS ___________________________ CITY, STATE, ZIP PRO SE AFFIDAVIT TO ACCOMPANY PETITION FOR ORDER OF RELIEF I, the undersigned, being under oath and declare under penalty of perjury, that I do not have anattorney to represent me in this case, that I represent myself in this case, that I am the petitioner in theabove-stated bankruptcy case under Title 11 of the United States Code, and that the answers given beloware true according to the best of my knowledge, information and belief. Did anyone assist you in any way in the preparation of this petition? ANSWER: YES ( ) NO ( ) If someone did assist you, list their name and address: ______________________________ NAME ______________________________ ADDRESS ______________________________ _________________________ CITY, STATE, ZIP CODE TELEPHONE NUMBER Did the person assisting you charge or collect any money for helping you in any way? ANSWER: YES ( ) NO ( ) IF "YES", HOW MUCH ($_______) Have you filed a bankruptcy case in the past? ANSWER: YES ( ) NO ( ) If you have filed a bankruptcy case in the past, list the case number, chapter and judge:___________________________________________ ___________________________________ PRO SE PETITIONERSubscribed and sworn to before me on the ____ day of ______________,______ _________________________________ ___________________________________ NOTARY PUBLIC DEPUTY CLERKF61 (psafdt)04/04