R.I. Local Bankr. Form C.1 LBR 1007-1(a) New 6-1-2006 UNITED STATES BANKRUPTCY COURT FOR THE DISTRICT OF RHODE ISLAND ------------------------------* In re: : : Debtor(s) BK No. Chapter : ------------------------------* CERTIFICATION BY PRO SE DEBTOR On , a voluntary bankruptcy petition was filed by the undersigned, appearing pro se and without legal counsel. Certification is hereby made that: CHECK EITHER ITEM 1 OR 2 ONLY. IF ITEM 2 IS SELECTED, PROVIDE NAME AND ADDRESS OF ASSISTANCE PROVIDER: (1) ____________ No persons and/or entities, other than myself/us, assisted in the preparation, typing, and/or completion of said petition and/or related schedules; (2) ____________ the following persons and/or entities constitute the only persons/entities who assisted in the preparation, typing, and/or completion of said petition and all related schedules, and represent the only sums paid by me/us for these services: NAME AND ADDRESS OF ASSISTANCE PROVIDER TOTAL AMOUNT PAID ______________________________________________ ______________________________________________ ______________________________________________ _____________________ I hereby certify under penalty of perjury that the above information is true and accurate to the best of my knowledge. I am aware that the providing of false or incomplete information may result in the denial of discharge in bankruptcy and/or other sanctions. DATE ___________________________ SIGNATURE Phone number ( )