LBF 5005-4B UNITED STATES BANKRUPTCY COURT DISTRICT OF NEW HAMPSHIRE In re: Bk. No. *-JMD or -MWV Chapter * *, Debtor(s) DECLARATION REGARDING ELECTRONIC FILING PART 1 - Declaration of Declarant: I [We] _____________________________________________________, the undersigned declarant(s), hereby declare under penalty of perjury that I have signed the document identified below and that the information contained in the electronically filed document identified below is true and correct, to the best of my knowledge and belief. I understand that this DECLARATION REGARDING ELECTRONIC FILING is to be filed with the Clerk after the document identified below has been filed electronically but, in no event, no later than 5 business days after the document has been filed. I acknowledge receipt of a copy of the electronically filed document. PART 2 - Identification of Document: [Name of document] dated ______________, consisting of ___ pages I understand and agree that failure to file the signed original of this DECLARATION is grounds for the Court to strike the document identified above from the record in this proceeding. Dated: ____________________________________ ________________________________________ ______ Name: Title: (Insert acknowledgment if required) Part 3 - Declaration of Attorney: I declare that, to the best of my knowledge, information and belief, formed after an inquiry reasonable under the circumstances, that the document identified above is not being presented for any improper purpose; that the allegations and other factual contentions have, or will have, evidentiary support; and that the denials of factual contentions are warranted. I further certify that the declarant signed this Declaration and authorized me to electronically file the document identified above, that I gave the declarant a copy of the electronically filed document identified above, and that the document identified in the attached Notice of Electronic Filing from the CM/ECF system is the document identified above. Dated: ____________________________________ ________________________________________ ______ Name: Attach the Notice of Electronic Filing as an Exhibit. American LegalNet, Inc. www.FormsWorkflow.com LBF 5005-4B (FILE ORIGINAL WITH COURT. DO NOT FILE ELECTRONICALLY.) American LegalNet, Inc. www.FormsWorkflow.com