L.B.F. 2016-3A 223Short Form224 Application of Counsel for Debtor for Compensation and Reimbursement of Expenses in Chapter 13 Case UNITED STATES BANKRUPTCY COURT FOR THE EASTERN DISTRICT OF PENNSYLVANIA In re: ) Chapter 13 ) Debtor(s) ) ) Bky. No. ) APPLICATION FOR COMPENSATION AND REIMBURSEMENT OF EXPENSES Name of applicant applies under 247 330 of the Bankruptcy Code for an award of compensation and reimbursement of actual, necessary expenses and represents: 1.Applicant is counsel for the debtor. 2.The debtor filed a petition under chapter 13 of the Bankruptcy Code on (date). 3.The debtor222s annualized current monthly income as set forth on Form B22C is: above median (the amount on line 15 is not less than the amount on line 16). below median (the amount on line 15 is less than the amount on line 16). 4.All services rendered and expenses incurred for which compensation or reimbursement isrequested were performed or incurred for or on behalf of the debtor, the services and expenseswere actual and necessary, and the compensation requested for those services is reasonable. 5.Applicant requests an award of compensation of $ for providing the followingservices: (Description of Services) 6.Applicant requests reimbursement of expenses in the amount of $ for the followingexpenses: (Description of Expenses) 7.The debtor paid Applicant $ prior to the filing of the petition. 8.A copy of the Applicant222s disclosure of compensation pursuant to Fed. R. Bankr. P. 2016(b) isattached hereto as Exhibit 223A.224 9.None of the compensation paid to applicant will be shared with any person other than amember or regular associate of applicant222s law firm unless 11 U.S.C. 247504(c) applies. American LegalNet, Inc. www.FormsWorkFlow.com WHEREFORE, Applicant requests an award of $ in compensation and of $ in reimbursement of actual, necessary expenses. Date: Signed: [Applicant222s name] 205205205205205205205205205 [Firm Name] 205205205205205205205205205205205.. [Address] 205205205205205205205205205205205205... [Phone No.] 205205205205205205205205205205205... [Fax No.] 205205205205205205205205205205205205... [E-mail address] 205205205205205205205205205205 American LegalNet, Inc. www.FormsWorkFlow.com