LBR Form 2016-1(b) UNITED STATES BANKRUPTCY COURT FOR THE SOUTHERN DISTRICT OF OHIO ____________ DIVISION AT ____________ In re: Case No: Chapter 13 Debtor(s) Judge DISCLOSURE OF COMPENSATION OF ATTORNEY FOR DEBTOR AND APPLICATION FOR ALLOWANCE OF FEES IN CHAPTER 13 CASE I. Disclosure 1. Pursuant to 11 U.S.C. § 329(a) and Fed. R. Bankr. P. 2016(b), I certify that I am the attorney for the above-named debtor(s) and that compensation paid to me within one year before the filing of the petition in bankruptcy, or agreed to be paid to me, for services rendered or to be rendered on behalf of the debtor(s) in contemplation of or in connection with the bankruptcy case is as follows: For legal services I have agreed to accept . . . . . . . . . . . . . . . . . . . . . . . . . $___________ Prior to the filing of this statement I have received . . . . . . . . . . . . . . . . . . $___________ Balance due . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . $___________ 2. The source of the compensation paid to me was: Debtor 3. The source of compensation to be paid to me is: Debtor 4. Other (specify) Other (specify) I have not agreed to share the above-disclosed compensation with any other persons unless they are members and/or associates of my law firm. I have agreed to share the above-disclosed compensation with another person or persons who are not members or associates of my law firm. A copy of the agreement, together with a list of the names of the people sharing in the compensation, is attached. American LegalNet, Inc. www.FormsWorkFlow.com II. Application 5. I hereby apply for an allowance of fees in the amount set forth above. I understand and agree that the Court may approve, without itemization, an allowance of fees not to exceed $3,500, for rendering the legal services set forth below. If I seek payment of fees in excess of $3,500, I will file a separate application that sets forth the total amount of the fee requested, and that includes an itemization of all legal services performed, the hourly rate at which the services were performed, and the actual time spent by the case attorney, any other attorney, paralegal or professional person for whom fees are sought. Any request for reimbursement of expenses shall include an itemization of the expenses. a. b. c. d. e. f. g. h. i. j. k l. m. 6. Analysis of the debtor’s financial situation, and rendering advice to the debtor in determining whether, and under what chapter, to file a petition in bankruptcy; Preparation and filing of any petition, schedules, statements of affairs and amendments thereto that may be required; Preparation and filing of chapter 13 plan, and any pre-confirmation amendments thereto that may be required; Preparation and filing of payroll orders and amended payroll orders; Representation of the debtor at the meeting of creditors and confirmation hearing; and any continued hearings thereof; Filing of address changes; Routine phone calls and questions; Review of claims; Review of notice of intention to pay claims; Preparation and filing of objections to non-real estate and non-tax claims; Preparation and filing of first motion to suspend or reduce payments; Preparation and filing of debtor’s certification regarding issuance of discharge order; and Any other duty as required by local decision or policy. By agreement with the debtor(s), the above-disclosed fee does not include the following services: ____________________ Date _________________________________ Signature of Attorney Bar No. Name of Firm Street/PO Address City, State, Zip Phone Number Fax Number Email address American LegalNet, Inc. www.FormsWorkFlow.com