FORM 1007-1E (02/12) UNITED STATES BANKRUPTCY COURT NORTHERN DISTRICT OF OKLAHOMA IN RE: ______________________________, Debtor(s). PRO SE FILING DISCLOSURE 1. (a) Did you receive assistance from one or more persons, businesses, or websites in preparing or filing your bankruptcy petition or schedules in this case? Yes No If so, please provide the name, address, phone number, website address, and e-mail address of each person or business that assisted you. (If you do not have this information presently available, please bring it to your first meeting of creditors.) Case No. ___________ Chapter ____ (b) 2. (a) If you received assistance, have you paid or promised to pay that person or business a fee for assisting you in filing your petition or schedules? Yes No If so, what amount did you pay or promise to pay? What was the form of payment? cash credit card check other:_____________ To whom was the payment made? ____________________________________________ (b) (c) (d) 3. If you received assistance, were other types of bankruptcy relief explained to you? Yes No Other comments: I declare under penalty of perjury that the information provided herein is true and correct. Signature of Debtor Address: Telephone Number: Date Signature of Joint Debtor (if any) Address: Telephone Number: Date American LegalNet, Inc. www.FormsWorkFlow.com