UNITED STATES BANKRUPTCY COURT EASTERN DISTRICT OF NEW YORK --------------------------------------------------------------------x In re: Case No. Chapter: Debtor(s) --------------------------------------------------------------------x AFFIDAVIT PURSUANT TO E.D.N.Y. LBR 1009-1(a) , undersigned debtor herein, swears as follows: 1. 2. Debtor filed a petition under chapter of the Bankruptcy Code on . [indicate list(s), schedule(s) or Filed herewith is an amendment to statement(s) being amended] previously filed herein. 3. Annexed hereto is a listing setting forth the specific additions or corrections to, or deletions from, the affected list(s), schedule(s) or statement(s). The nature of the change (addition, deletion or correction) is indicated for each creditor or item listed. [If creditor records have been added or deleted, or mailing addresses corrected] An amended mailing matrix is annexed hereto, reflecting only changes adding or deleting as have been referred to above. 4. Dated: (Signature of Debtor) Sworn to before me this day of , . Notary Public, State of New York Reminder: No amendment of schedules is effective until proof of service in accordance with E.D.N.Y. LBR 1009-1(b) has been filed with the Court. If this amendment is filed prior to the expiration of the time period set forth in Fed. R. Bankr. P. 4004 and 4007, it will be deemed to constitute a motion for a 30-day extension of the time within which any added creditors may file a complaint to object to the discharge of the debtor and/or to determine dischargeability. This motion will be deemed granted without a hearing if no objection is filed with the Court and served on debtor within 14 days following filing of proof of service of this affidavit, all attachments and the amended schedules in accordance with EDNY LBR 1009-1. American LegalNet, Inc. www.FormsWorkFlow.com USBC-63 Rev. 12/16 AFFIDAVIT PURSUANT TO LOCAL RULE 1009-1(a) (Reverse Side) Instructions for Completion of Form, Pro Se Debtors E.D.N.Y. LBR 1009-1(a) requires that, whenever lists, schedules or statements are amended, an affidavit must be filed which sets forth the changes (additions, deletions, corrections) which have been made. In re. Name(s) of debtor(s) as it/they appear on the petition. Case No. The bankruptcy case number assigned at the time of filing of the petition, including the three-digit judge code. EXAMPLE: 197-10345-260 Chapter. The bankruptcy chapter under which relief is being sought (7, 9, 11, 12, 13 or 15). Debtor. Name(s) of debtor(s) signing affidavit. Filed petition under chapter. Re-enter chapter. Filed petition on. Enter the date the petition was filed. Amendment to. Specify list(s), schedule(s) or statement(s) affidavit relates to (e.g., Schedule D, E/F, Statement of Financial Affairs for Individuals Filing Bankruptcy or Statement of Financial Affairs for Non-Individuals Filing for Bankruptcy). Listing. Attach a listing of all changes, and specify the nature of each change. EXAMPLE: Schedule E/F has been amended to add the following creditor: Discover PO Box 8003 Hilliard, OH 43026 7/93 $2,235.35 Matrix. If creditors have been added or deleted, or if address corrections have been made, a revised creditor mailing matrix must be submitted, reflecting only changes adding or deleting creditors. Signature. The form must be signed by the debtor(s) and notarized. The date of the signing must be indicated at the prompt on the lower left of the form. *** FEE: A $31 fee is due if the nature of the amendment is to add or delete creditors from the schedules, or to make changes as to amount owed, nature of debt, etc. Acceptable forms of payment include cash, money orders and bank checks. Make money order or bank check payable to Clerk, U.S. Bankruptcy Court. Debtors' personal checks cannot be accepted. Do NOT send cash through the mail. SERVICE: If creditors have been added, you are responsible for mailing to each such creditor a copy of the notice that the Court issued (and which you should already have received a copy of) advising of the filing of the case, the meeting of creditors and the fixing of certain deadlines. You should file a certificate of service of the notice along with the schedules. (A form of certificate of service is available from the Customer Service Representative) IMPORTANT: No amendment of schedules is effective until proof of service in accordance with E.D.N.Y. LBR 1009-1(b) has been filed with the Court. American LegalNet, Inc. www.FormsWorkFlow.com Aff1009r.63 Rev.12/16