MOW 1007-1.3 (1/11) In re: UNITED STATES BANKRUPTCY COURT WESTERN DISTRICT OF MISSOURI ) ) Case No. Debtor(s), Full Social Security Number(s) ) DECLARATION RE: ELECTRONIC FILING PART I - DECLARATION OF PETITIONER: I [We] _______________________ and ______________________, the undersigned debtor(s), corporate officer, partner, or member, hereby declare under penalty of perjury that the information I have given or will give 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 and any future amendments of these documents to the United States Bankruptcy Court, United States Trustee and Panel Trustee. I understand that this DECLARATION RE: ELECTRONIC FILING is to be filed with the Clerk after the petition has been filed electronically but, in any event, no later than 7 days after the petition has been filed. I understand that failure to file the signed original of this DECLARATION will cause my case to be dismissed without further notice. I [We] hereby designate my attorney, whose signature, name, address, Missouri Bar No., telephone and fax numbers are set forth below, as my agent to receive service of process and service of all pleadings in all proceedings, including adversary actions and contested matters, pursuant to Bankruptcy Rule 7004(b)(9), in this Court arising in this case. This designation shall expire upon entry of the final decree. 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 the petition. I declare under penalty of perjury that the foregoing social security number is true and correct. G [If petitioner is a corporation, partnership or limited liability entity] 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 Joint Debtor (If joint case, both spouses must sign) Dated: __________________ _______________________________________________________ Authorized Corporate Officer, Partner, or Member PART II - DECLARATION OF ATTORNEY: I declare under penalty of perjury that I have reviewed the above debtor's[s'] petition, schedules, statements and that the information is complete and correct to the best of my knowledge. The debtor(s) signed this Declaration before I submitted the petition, schedules and statements. I will give the debtor(s) a copy of all pleadings and information to be filed with, or received from, the United States Bankruptcy Court, and have complied with all other requirements in the most recent General Order, Administrative Procedures for Electronic Case Filing Manual and this court's Local Rules. I have informed the individual petitioner that [he and/or she] 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 upon all information of which I have knowledge. Dated: ____________________ Signed:__________________________________________ Attorney for Debtor(s), Missouri Bar No. Attorney Address/ E-mail Address Attorney Phone No./ Fax No. Instructions: Fill in applicable sections. Debtor(s) signature must be an image of original or electronically captured. Typed names alone do not meet local rule requirements. File document electronically for all cases filed on or after 1/1/11 ECF Event: Bankruptcy>Other>Declaration Re: Electronic Filing American LegalNet, Inc. www.FormsWorkFlow.com