BK 92 UNITED STATES BANKRUPTCY COURT WESTERN DISTRICT OF TENNESSEE ________________________________________________________________________ In re Case No. Chapter Debtor(s)* Social Security No(s): H W- _____________________________________________________________________________________ DISCLOSURE OF COMPENSATION UNDER 11 U.S.C. § 329 AND FED. R. BANKR. P. 2016(b) _____________________________________________________________________________________ I certify that I am the attorney for the above-named debtor(s) and that the compensation paid or agreed to be paid to me for services rendered or to be rendered in behalf of the debtor in or in connection with a case under title 11 of the United States Code, such payment or agreement having been made after one year before the date of the filing of the petition, is as follows: $ paid, $ to be paid, that the source of the compensation paid was , and that the source of the compensation agreed to be paid is I have I have not agreed to share this compensation with any other person. [If appropriate] The details of such sharing or agreement to share are as follows [except that no such details are required of any agreement for sharing of the compensation with a member or regular associate of the attorney's law firm]: Dated:_____________________ ___________________________________________ Attorney for Debtor ___________________________________________ Address ___________________________________________ Telephone No.:_______________________________ State Bar Disciplinary No.:________________________ * Include all names used by debtor within last 6 years American LegalNet, Inc. www.USCourtForms.com