(Rev. 3/2006: Previous Versions are Obsolete) UNITED STATES BANKRUPTCY COURT WESTERN DISTRICT OF NEW YORK COVER SHEET FOR SCHEDULES, STATEMENTS, LISTS AND/OR AMENDMENTS Case Name: Case No. Chapter A. IDENTIFY TYPE OF DOCUMENT BEING FILED: (Select either #1, #2 or #3) #1--Amendment to previously filed document (Go to Sec. B) #2--Schedule/Statement not previously filed (Go to Sec. B) #3–Schedule of Post-Petition Debts (result of conversion–no fee due) (Go to Sec. D) B. SUMMARIZE SPECIFICS OF DOCUMENT BEING FILED BY CHECKING APPLICABLE DATA ELEMENTS: Amendment to Case Caption: (Please specify) Name Social Security/Tax ID # aka/dba/fkba/fka information Petition Page: (Please specify) County Resident/Mailing address Signature Debtor(s) Attorney Corporation/Partnership Exhibit B Statistical/Administrative Information Creditor Matrix Summary of Schedules Schedules: (Please check schedules attached to this Cover Sheet) Schedule A Schedule B Schedule C Schedule D (Go to Sec. C) Schedule E (Go to Sec. C) Schedule F (Go to Sec. C) Schedule G Schedule H Schedule I Schedule J Statement of Financial Affairs Statement Pursuant to Rule 2016(b) Exhibit A Chapter 13 Plan (Pre-confirmation): Decrease Payments Increase Payments Increases length of plan Other: (Please specify) FOR CHANGES AFFECTING SCHEDULE(S) D,E, or F, , THE LIST OF CREDITORS, MATRIX, OR MAILING LIST, PROCEED TO SECTION “C” OF THIS FORM. OTHERWISE, PROCEED TO SECTION “D.” C. CREDITOR/SCHEDULE INFORMATION: (Select either #1, #2 or #3) #1--Creditors are being added or deleted by this amendment/schedule, AND The $26.00 amendment fee is attached A matrix in the format prescribed by the Clerk with the complete names and addresses of the parties added is attached. Note: Do not repeat creditor information from a previously filed matrix. #2--Schedule(s) of creditors (Schedules D, E, F), list of creditors, matrix or mailing list is being amended for purposes other than adding or deleting creditors. The $26.00 fee is attached for this amendment [e.g. changing amount of a debt or classification of a debt]. Q The $26.00 fee does not apply for this amendment [e.g. change of address of a creditor or change of attorney]. #3 – No Creditors are being added or deleted. D. CERTIFICATION OF SERVICE, ATTORNEY’S DECLARATION AND DEBTOR’S UNSWORN DECLARATION CERTIFICATION OF SERVICE Attach an “Affidavit of Service” listing each party served with a copy of the referenced document(s), this cover sheet and a copy of the §341 Meeting Notice (if applicable). Be sure to include the U.S. Trustee and the Case Trustee. DECLARATION of Attorney [Attorney or debtor(s), if pro se, must sign.] I declare that the above information contained on this cover sheet may be relied upon by the Clerk of Court as a complete and accurate summary of the information contained in the documents attached. Dated __________________ Signature: _________________________________________ DECLARATION of Debtor(s) [Required if declaration is not completed on the document(s) itself or by separate instrument.] I declare under penalty of perjury that I have read this cover sheet and the attached schedules, lists, statements, etc., consisting of _______ sheets, numbered 1 through _____, and that they are true and correct to the best of my knowledge, information and belief. Dated: _____________ Signature:______________________________________________________________ (debtor) Dated: _____________ Signature:______________________________________________________________ (joint debtor, if any) Please contact our Financial Department with any questions regarding whether or not a fee is due at (716) 551-4130. American LegalNet, Inc. www.USCourtForms.com