Fill in this information to identify the case: Debtor 1 Debtor 2 __________________________________________________________________ First Name Middle Name Last Name (Spouse, if filing) First Name ________________________________________________________________ Middle Name Last Name United States Bankruptcy Court for the: _____________________ District of _________ (State) Case number (If known) ___________________________________________ Chapter ____________ Official Form 119 Bankruptcy Petition Preparer's Notice, Declaration, and Signature 12/15 Bankruptcy petition preparers as defined in 11 U.S.C. § 110 must fill out this form every time they help prepare documents that are filed in the case. If more than one bankruptcy petition preparer helps with the documents, each must sign in Part 3. A bankruptcy petition preparer who does not comply with the provisions of title 11 of the United States Code and the Federal Rules of Bankruptcy Procedure may be fined, imprisoned, or both. 11 U.S.C. § 110; 18 U.S.C. § 156. Part 1: Notice to Debtor Bankruptcy petition preparers must give the debtor a copy of this form and have the debtor sign it before they prepare any documents for filing or accept any compensation. A signed copy of this form must be filed with any document prepared. Bankruptcy petition preparers are not attorneys and may not practice law or give you legal advice, including the following: whether to file a petition under the Bankruptcy Code (11 U.S.C. § 101 et seq.); whether filing a case under chapter 7, 11, 12, or 13 is appropriate; whether your debts will be eliminated or discharged in a case under the Bankruptcy Code; whether you will be able to keep your home, car, or other property after filing a case under the Bankruptcy Code; what tax consequences may arise because a case is filed under the Bankruptcy Code; whether any tax claims may be discharged; whether you may or should promise to repay debts to a creditor or enter into a reaffirmation agreement; how to characterize the nature of your interests in property or your debts; or what procedures and rights apply in a bankruptcy case. The bankruptcy petition preparer ________________________________________________________________ has notified me of Name any maximum allowable fee before preparing any document for filing or accepting any fee. ___________________________________________________________________________________ Signature of Debtor 1 acknowledging receipt of this notice Date _________________ MM / DD / YYYY ___________________________________________________________________________________ Signature of Debtor 2 acknowledging receipt of this notice Date _________________ MM / DD / YYYY Official Form 119 Bankruptcy Petition Preparer's Notice, Declaration, and Signature page 1 105 American LegalNet, Inc. www.FormsWorkFlow.com Debtor 1 First Name _______________________________________________________ Middle Name Last Name Case number (if known)_____________________________________ Part 2: Declaration and Signature of the Bankruptcy Petition Preparer Under penalty of perjury, I declare that: I am a bankruptcy petition preparer or the officer, principal, responsible person, or partner of a bankruptcy petition preparer; I or my firm prepared the documents listed below and gave the debtor a copy of them and the Notice to Debtor by Bankruptcy Petition Preparer as required by 11 U.S.C. §§ 110(b), 110(h), and 342(b); and if rules or guidelines are established according to 11 U.S.C. § 110(h) setting a maximum fee for services that bankruptcy petition preparers may charge, I or my firm notified the debtor of the maximum amount before preparing any document for filing or before accepting any fee from the debtor. Printed name ________________________________ ______________________ Title, if any _______________________________________________________ Firm name, if it applies Number ______________________________________________________ Street ______________________________ Contact phone ____________________________________ __________ ______________ City State ZIP Code I or my firm prepared the documents checked below and the completed declaration is made a part of each document that I check: (Check all that apply.) Voluntary Petition (Form 101) Schedule I (Form 106I) Statement About Your Social Security Numbers Schedule J (Form 106J) (Form 121) Declaration About an Individual Debtor's Summary of Your Assets and Liabilities and Schedules (Form 106Dec) Certain Statistical Information (Form 106Sum) Statement of Financial Affairs (Form 107) Schedule A/B (Form 106A/B) Statement of Intention for Individuals Filing Schedule C (Form 106C) Under Chapter 7 (Form 108) Schedule D (Form 106D) Chapter 7 Statement of Your Current Monthly Income (Form 122A-1) Schedule E/F (Form 106E/F) Statement of Exemption from Presumption Schedule G (Form 106G) of Abuse Under § 707(b)(2) (Form 122A-1Supp) Schedule H (Form 106H) Chapter 7 Means Test Calculation (Form 122A-2) Chapter 11 Statement of Your Current Monthly Income (Form 122B) Chapter 13 Statement of Your Current Monthly Income and Calculation of Commitment Period (Form 122C-1) Income (Form 122C-2) (Form 103A) Chapter 13 Calculation of Your Disposable Application to Pay Filing Fee in Installments Application to Have Chapter 7 Filing Fee Waived (Form 103B) A list of names and addresses of all creditors (creditor or mailing matrix) Other _____________________________ Bankruptcy petition preparers must sign and give their Social Security numbers. If more than one bankruptcy petition preparer prepared the documents to which this declaration applies, the signature and Social Security number of each preparer must be provided. 11 U.S.C. § 110. _______________________________________________________________ Signature of bankruptcy petition preparer or officer, principal, responsible person, or partner ___ ___ ___ -- ___ ___ -- ___ ___ ___ ___ Social Security number of person who signed Date _________________ MM / DD / YYYY _______________________________________________________________ Printed name _______________________________________________________________ Signature of bankruptcy petition preparer or officer, principal, responsible person, or partner _______________________________________________________________ Printed name ___ ___ ___ -- ___ ___ -- ___ ___ ___ ___ Social Security number of person who signed Date _________________ MM / DD / YYYY page 2 Official Form 119 Bankruptcy Petition P