(Rev. 7/15: 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) #3­Schedule of Post-Petition Debts (result of conversion­no fee due) (Go to Sec. D) B. SUMMARIZE SPECIFICS OF DOCUMENT BEING FILED BY CHECKING APPLICABLE DATA ELEMENTS: Case Caption: Name aka/fka/dba/fdba Social Security/Tax ID # (Individuals must submit Form B21 in paper) Petition Page: County Resident/Mailing Address Statistical/Administrative Information Corporation/Partnership Exhibit B Signature: Debtor Attorney Summary of Schedules Schedules: (Please check all schedules attached) Schedule A Schedule D (Go to Sec. C) Schedule G Schedule J Schedule B Schedule E (Go to Sec. C) Schedule H Schedule C Schedule F (Go to Sec. C) Schedule I Statement of Financial Affairs Statement Pursuant to Rule 2016(b) Exhibit A Creditor Matrix Chapter 13 Plan (Pre-confirmation): Decrease Payments Increase Payments Increases length of plan Other : ___________________________________________________________________________________________ FOR CHANGES AFFECTING SCHEDULES 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 $30.00 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. The Clerk's office will not delete creditors unless a motion to delete creditors is granted. #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 $30.00 fee is attached for this amendment [e.g. changing amount of a debt or classification of a debt]. The $30.00 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) American LegalNet, Inc. www.FormsWorkFlow.com