UNITED STATES BANKRUPTCY COURT WESTERN DISTRICT OF LOUISIANA IN RE: BANKRUPTCY NO. DECLARATION RE: ELECTRONIC FILING OF PETITION, SCHEDULES, & STATEMENTS and STATEMENT OF SOCIAL SECURITY NUMBER(S) PART I - DECLARATION OF PETITIONER(S) I [We] and the undersigned debtor(s), hereby declare under penalty of perjury that the information I have given my attorney and the information provided in the electronically filed petition, statements, and schedules is true and correct. I consent to my attorney sending my petition, this declaration, statements and schedules to the United States Bankruptcy Court. I understand that this DECLARATION RE: ELECTRONIC FILING is to be filed with the Clerk no later than forty-eight (48) hours following the date the petition was electronically filed, and all schedules and statements are to be filed no later than fourteen (14) days following the date the petition was electronically filed. I understand that the original of this DECLARATION RE: ELECTRONIC FILING OF PETITION, SCHEDULES, & STATEMENTS will be maintained by the Clerk of Court. I further understand that failure to file the signed original of the DECLARATION will cause my case to be dismissed pursuant to F.R.B.P. without further notice. G [If petitioner is an individual whose debts are primarily consumer debts and has chosen to file under chapter 7] I am aware that I may proceed under chapter 7, 11, 12 or 13 of 11 United States Code, understand the relief available under each such chapter, and choose to proceed under chapter 7. I request relief in accordance with the chapter specified in this petition. G [If petitioner is a corporation or partnership] I declare under penalty of perjury that the information provided in this petition is true and correct, and that I have been authorized to file this petition on behalf of the debtor. The debtor requests relief in accordance with the chapter specified in this petition. Signed: Debtor Date Signed: Joint Debtor Date PART II - DECLARATION OF ATTORNEY I declare under penalty of perjury that I have reviewed the above debtor's petition and that the information is complete and correct to the best of my knowledge. The debtor(s) will have signed this form before I submit the petition, schedules, and statements. I will give the debtor(s) a copy of all forms and information to be filed with the United States Bankruptcy Court. I further declare that I have examined the above debtor's petition, schedules, and statements and, to the best of my knowledge and belief, they are true, correct, and complete. If an individual, I declare that I have informed the petitioner that [he, she or they] may proceed under chapter 7, 11, 12 or 13 of Title 11, United States Code, and have explained the relief available under each such chapter. This declaration is based on all information of which I have knowledge. Signed: Attorney for Debtor(s) Date PART III - STATEMENT OF SOCIAL SECURITY NUMBER(S) - RULE 1007(f) 1. Name of Debtor (Last, First, Middle): (Check the appropriate box and, if applicable, provide the required information.) G Debtor has a Social-Security Number and it is (If more than one, state all.) - - G Debtor does not have a Social-Security Number but has an Individual Taxpayer-Identification Number (ITIN), and it is _____________________________________________________. G Debtor does not have either a Social-Security Number or an Individual Taxpayer-Identification Number (ITIN). 2. Name of Joint Debtor (Last, First, Middle): (Check the appropriate box and, if applicable, provide the required information.) (If more than one, state all.) G Joint Debtor has a Social-Security Number and it is (If more than one, state all.) - - G Joint Debtor does not have a Social-Security Number but has an Individual Taxpayer-Identification Number (ITIN), and it is _________________________________________________________. G Joint Debtor does not have either a Social-Security Number or an Individual Taxpayer-Identification Number (ITIN). I declare under penalty of perjury that the foregoing is true and correct. (If more than one, state all.) Signed: Debtor Date Signed: Joint Debtor Date (08/31/11) *Joint debtors must provide information for both spouses. Penalty for making a false statement: Fine of up to $250,000 or up to 5 years imprisonment or both. 18 U.S.C. §§ 152 and 3571. American LegalNet, Inc. www.FormsWorkFlow.com