L.B.F. 2016-4 STATEMENT OF PRO SE DEBTOR Debtor222 Name Case No. Address Chapter of Case Telephone Number (home) Date Case Filed Telephone Number (work) 1.List the name, address, and telephone number of any person or business assisting you infiling or preparing papers for this case: 2.State how you were referred to the person or business named above or the source ofadvertisement you responded to. 3. a. Total fee charged by person or business named above $ b.Amount of fee paid as of the date you filed bankruptcy $ c.Did the preparer tell you the amount of court costs that must be paid to file yourcase?YES NO (circle one) 4.Were various chapters or types of bankruptcy explained to you? YES NO (circle one) Other Comments 5.Did the preparer explain to you that you have the right to claim certain property asexempt? YES NO (circle one) American LegalNet, Inc. www.FormsWorkFlow.com 6.Did the preparer give you a copy of the papers he prepared for you? YES NO (circle one) Date: American LegalNet, Inc. www.FormsWorkFlow.com