United States Bankruptcy Court Western District of Tennessee FormLF1 (10/05) In re Case No. Debtor(s) Chapter DEBTOR’S APPLICATION TO PAY CASE FILING FEE IN INSTALLMENTS 1. In accordance with Fed. R. Bankr. P. 1006, I apply for permission to pay the case filing fee amounting to $_______________ in installments. 2. I am unable to pay the filing fee except in installments. 3. Until the filing fee is paid in full, I will not make any additional payment or transfer any additional property to an attorney or any other person for services in connection with this case. 4. The number of installments shall not exceed four(4), and the final installment shall be payable not later than 120 days after filing the petition. For cause shown, the court may extend the time of any installment, provided the last installment is paid not later than 180 days after filing the petition. Fed. R. Bankr. P. 1006(b)(2). 5. I understand that if I fail to pay any installment when due, my bankruptcy case may be dismissed and I may not receive a discharge of my debts. _____________________________________________ Signature of Attorney Date _________________________________________ Signature of Debtor Date (In a joint case, both spouses must sign.) _____________________________________________ _________________________________________ Name of Attorney Signature of Joint Debtor (if any) Date ------------------------------------------------------------------------------------------------------------------------------------------------------------------DECLARATION AND SIGNATURE OF NON-ATTORNEY BANKRUPTCY PETITION PREPARER (See 11 U.S.C. § 110) I declared under penalty of perjury that:(1) I am a bankruptcy petition preparer as defined in 11 U.S.C. § 110;(2) I prepared this document for compensation and have provided the debtor with a copy of this document and the notices and information required under 11 U.S.C. §§ 110(b), 110(h), and 342(b);(3) if rules or guidelines have been promulgated pursuant to 11 U.S.C. § 110(h) setting a maximum fee for services chargeable by bankruptcy petition preparers, I have given the debtor notice of the maximum amount before preparing any document for filing for a debtor or accepting any fee from the debtor, as required under that section; and (4) I will not accept any additional money or other property from the debtor before the filing fee is paid in full. ____________________________________________ _________________________________________ Printed or Typed Name and Title, if any, of Bankruptcy Petition Preparer Social Security No. (Required by 11 U.S.C. § 110.) If the bankruptcy petition preparer is not an individual, state the name, title (if any), address, and social security number of the officer, principal, responsible person, or partner who signs the document. ____________________________________________ ____________________________________________ Address x___________________________________________ Signature of Bankruptcy Petition Preparer __________________________________________ Date Names and Social Security numbers of all other individuals who prepared or assisted in preparing this document, unless the bankruptcy petition preparer is not an individual: If more than one person prepared this document, attach additional signed sheets conforming to the appropriate Official Form for each person. A bankruptcy petition preparer’s failure to comply with the provisions of title 11 and the Federal Rules of Bankruptcy Procedure may result in fines or imprisonment or both. 11 U.S.C. § 110; 18 U.S.C. § 156. CLERK’S APPROVAL Based upon the foregoing, the Clerk grants the debtor’s application pursuant to L.B.R. 1006 (b)-1(b). This approval is without prejudice to judicial review, which could result in a hearing to show cause why the Clerk’s approval should not be set aside or otherwise modified. JED G. WEINTRAUB U.S. BANKRUPTCY COURT CLERK By:___________________________________________ Deputy Clerk Date:__________________________________________ American LegalNet, Inc. www.USCourtForms.com