Form 3A (10/05) United States Bankruptcy Court _______________ District Of ______________ In re _______________________________________, Debtor Case No. ___________________ Chapter ____________ APPLICATION TO PAY FILING FEE IN INSTALLMENTS 1. In accordance with Fed. R. Bankr. P. 1006, I apply for permission to pay the filing fee amounting to $______________ in installments. 2. I am unable to pay the filing fee except in installments. 3. Until the filing fee is paid in full, I will not make any additional payment or transfer any additional property to an attorney or any other person for services in connection with this case. 4. I propose the following terms for the payment of the Filing Fee.* $ _____________________ Check one With the filing of the petition, or On or before ______________ $ _____________________ on or before ________________________________________ $ _____________________ on or before ________________________________________ $ _____________________ on or before ________________________________________ * The number of installments proposed shall not exceed four (4), and the final installment shall be payable not later than 120 days after filing the petition. For cause shown, the court may extend the time of any installment, provided the last installment is paid not later than 180 days after filing the petition. Fed. R. Bankr. P. 1006(b)(2). 5. 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 PREPARER (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 both. 11 U.S.C. § 110; 18 U.S.C. § 156. Form 3A Contd. (10/05) United States Bankruptcy Court _______________ District Of ______________ In re _______________________________________, Debtor Case No. ___________________ Chapter ____________ ORDER APPROVING PAYMENT OF FILING FEE IN INSTALLMENTS G IT IS ORDERED that the debtor(s) may pay the filing fee in installments on the terms proposed in the foregoing application. G IT IS ORDERED that the debtor(s) shall pay the filing fee according to the following terms: $ _____________________ Check one With the filing of the petition, or On or before ______________ $ _____________________ on or before ________________________________________ $ _____________________ on or before ________________________________________ $ _____________________ on or before ________________________________________ G IT IS FURTHER ORDERED that until the filing fee is paid in full the debtor(s) shall not make any additional payment or transfer any additional property to an attorney or any other person for services in connection with this case. BY THE COURT Date: ____________________ __________________________________________ United States Bankruptcy Judge