In re: UNITED STATES BANKRUPTCY COURT Eastern District of Michigan ______________________ Case No. Chapter: Debtor(s) / Hon. DECLARATION UNDER PENALTY OF PERJURY FOR DEBTOR(S) WITHOUT AN ATTORNEY The debtor(s) shall answer the following questions: 1. 2. Did you have help in preparing the documents for your bankruptcy filing : [ ]Yes [ ]No If you did have help, who helped you: Name Address City/State/Zip Telephone No. Soc. Sec. No. 3. If you did have help, what did you give or promise to give for this help? (Fill in all blanks) Money Paid Owed Note: Property What Value $ What Value $ Services $ $ Per Administrative Order 10-21. The maximum allowable fee chargeable by a bankruptcy petition preparer is $100.00. 4. Did you make any payment to the preparer for Court costs in connection with filing the petition? [ ] Yes [ ] No If so, how much $ I declare under penalty of perjury that the above statements are true. Debtor's Signature Print Name Address Telephone No. W A R NIN G: Debtor's Signature Print Name Address Telephone No. Bankruptcy Petition Preparer Print Name Address Telephone No. It is a federal crime to file a document containing false information in a federal court proceeding. Penalty for false declaration; Fine of not more than $250,000 or imprisonment for not more than 5years or both-18 U.S.C. §152 and U.S.C. §3571. American LegalNet, Inc. www.FormsWorkFlow.com