UNITED STATES BANKRUPTCY COURT DISTRICT OF OREGON In Re: ) ) ) ) ) ) Case No. ________________________ ELECTRONIC FILING DECLARATION (FOR INDIVIDUAL DEBTORS) Debtor(s). Check if Applicable G Petition (Including Exhibit D if applicable) G Chapter 7 Debtor's Statement of Intention G Declaration Concerning Debtor's Schedules G Statement of Financial Affairs G Statement of Monthly Income G Statement of Social Security Numbers G Other (specify): _________________________________ PART I ­ DECLARATION OF DEBTOR(S) Date Signed: ______________ Date Signed: ______________ Date Signed: ______________ Date Signed: ______________ Date Signed: ______________ Date Signed: ______________ Date Signed: ______________ I/We, the undersigned debtor(s), hereby declare under penalty of perjury that I/we: 1. signed each above-referenced document and gave it to my (our) attorney, whose name appears below; 2. authorize and instruct my (our) lawyer to: a. electronically file the document(s), with "/s/" and my (our) typed name(s) in lieu of my (our) signature(s); b. electronically file a scanned copy of this completed and signed LBF 5005; c. scan and destroy the document(s), but not this LBF 5005; and d. retain a scanned electronic replica of the document(s), and the signed original of this form, for the period required by LBR 5005-4(e). 3. agree that the electronic copy of the document(s) my (our) lawyer retains may serve as the original for all purposes. Signature of Debtor Printed Name of Debtor Date Signature of Joint Debtor (if applicable) Printed Name of Joint Debtor PART II ­ DECLARATION OF ATTORNEY Date I declare under penalty of perjury that, to the best of my knowledge after appropriate inquiry, the signature on this LBF 5005 purporting to be that of the debtor(s) is in fact that of the debtor(s). Signature of Attorney 5005 (5/1/17) Printed Name of Attorney Date American LegalNet, Inc. www.FormsWorkFlow.com