R.I. Local Form 1007-1.2 (Rev. 7/1/15) UNITED STATES BANKRUPTCY COURT FOR THE DISTRICT OF RHODE ISLAND - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - * In re: : : BK No. Debtor(s) 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 ( ) WOULD YOU LIKE TO RECEIVE COURT NOTICES SOONER BY E-MAIL INSTEAD OF REGULAR MAIL? See reverse side for information about this new electronic noticing service available to debtors. American LegalNet, Inc. www.FormsWorkFlow.com DEBTOR222S ELECTRONIC NOTICING REQUEST (DeBN) What is DeBN? 226 DeBN is a FREE service that allows debtors to request delivery of orders and court-generated notices by email rather than by U.S. Mail. Who can sign up? 226 Both self-represented [pro se] debtors and debtors who are represented by an attorney can sign up for DeBN. How do I sign up for DeBN? 226 Signing up is easy! Simply print your email address, name and then sign below. For more information about the DeBN program, visit the Court's website at: www.rib.uscourts .gov. I am a debtor in this bankruptcy case, or the debtor's authorized representative if the debtor is a business, and I have read the above information and understand and agree to the terms and conditions set forth therein. Neither the U.S. Bankruptcy Court nor the BNC bears any liability for errors resulting from the information I have submitted on this form. Joint debtors who each request enrollment or already have a DeBN account must file separate forms. Signature: Date: Printed Name (and title if not the debtor): Email Address (type or print clearly): INITIAL REQUEST : Pursuant to Bankruptcy Rule 9036, I hereby request receipt of court notices and orders via email, instead of U.S. mail, from the Bankruptcy Noticing Center (BNC) through the U.S. Bankruptcy Court222s Debtor Electronic Bankruptcy Noticing (DeBN) program. I understand that this request is limited to receipt of only notices and orders entered by the U.S. Bankruptcy Court. I will continue to receive documents filed by all other parties, such as the trustee and creditors, via U.S. mail or in person pursuant to court rules. I understand that I will receive electronic notice of any documents filed by the court in any current or future bankruptcy or adversary case from any bankruptcy court district in which I am listed with the same name and address, including cases where I am listed as a creditor. I understand that the first time the BNC receives an email bounce-back (undeliverable email), my DeBN account will be automatically disabled. I will then receive notices and orders via U.S. mail, and I must refile an updated request form if I wish to reactivate my account. I understand that enrollment in DeBN is completely voluntary, and I may file a request to deactivate my account at any time. Official Use only: Deputy Clerk's Initial s: American LegalNet, Inc. www.FormsWorkFlow.com