Fill in this information to identify your 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 __________ Case number (If known) ___________________________________________ (State) Check if this is an amended filing Official Form 106Dec Declaration About an Individual Debtor's Schedules If two married people are filing together, both are equally responsible for supplying correct information. 12/15 You must file this form whenever you file bankruptcy schedules or amended schedules. Making a false statement, concealing property, or obtaining money or property by fraud in connection with a bankruptcy case can result in fines up to $250,000, or imprisonment for up to 20 years, or both. 18 U.S.C. §§ 152, 1341, 1519, and 3571. Sign Below Did you pay or agree to pay someone who is NOT an attorney to help you fill out bankruptcy forms? No Yes. Name of person__________________________________________________. Attach Bankruptcy Petition Preparer's Notice, Declaration, and Signature (Official Form 119). Under penalty of perjury, I declare that I have read the summary and schedules filed with this declaration and that they are true and correct. ______________________________________________ _____________________________ Signature of Debtor 1 Signature of Debtor 2 Date _________________ MM / DD / YYYY Date _________________ MM / DD / YYYY Official Form 106Dec Declaration About an Individual Debtor's Schedules American LegalNet, Inc. www.FormsWorkFlow.com