UNITED STATES BANKRUPTCY COURT EASTERN DISTRICT OF VIRGINIA Division In re Case No. Chapter Debtor(s) APPLICATION TO PAY FILING FEE IN INSTALLMENTS - EASTERN DISTRICT OF VIRG INIA 1. Applicant files herewith a petition commencing a voluntary (or joint) case under Title 11 of the United States Code and is unable to pay the filing fee except in installments. 2. Applicant proposes to pay such fees to the Clerk of the Bankruptcy Court upon the following terms (check applicable Chapter and fill in due dates): ___ Chapter 7: $75.00 upon filing of petition: __________________, 20___ $75.00 within one month thereafter: __________________, 20___ $59.00 within two months thereafter: __________________, 20___ ___ Chapter 11: $430.00 upon filing of petition: __________________, 20___ $409.00 within one month thereafter: __________________, 20___ Chapter l2: $105.00 upon filing of petition: __________________, 20___ $75.00 within one month thereafter: __________________, 20___ $59.00 within two months thereafter: __________________, 20___ ___ Chapter l3: $70.00 upon filing of petition: __________________, 20___ $70.00 within one month thereafter: __________________, 20___ $54.00 within two months thereafter: __________________, 20___ If any installment due date falls on a day that the Court is closed, payment shall be made not later than the next business day. 3. Applicant has neither paid any money nor transferred any property to the applicants attorney or any other person for services in connection with the bankruptcy, nor will any such payment be made until the filing fee is paid in full. 4. Applicant understands that the clerk shall issue an order of dismissal in any case where the initial installment payment required under FRBP 1006 and Local Bankruptcy Rule 1006-1(B) has t accompanied the filed petition or in any case where a subsno equent installment payment has not been received by the due date and the debtor will not receive a discharge. Applicant further understands that upon dismissal of the case, the remaining filing fee is nonetheless due and payable within ten (l0) days following dismissal of the case and that subsequent applications to pay filing fees in installments will be denied until all prior filing fees are paid in full. 5. Applicant requests that the Court approve this application. Date: ________________________ Signed: ________________________________________ Applicant (Debtor) Signed: ________________________________________ Codebtor (if joint petition) Address: _______________________________________ Signed: ________________________________ Debtors Attorney (if any) _______________________________________ American LegalNet, Inc. www.USCourtForms.com>>>> 2 CERTIFICATION AND SIGNATURE OF NON-ATTORNEY BANKRUPTCY PETITION PREPARER (See 11 U.S.C. 110) I certify that I am a bankruptcy petition preparer as defined by 11 U.S. C. 110, that I prepared this document for compensation, and that I have provided the debtor with a copy of this document. I also certify that I will not accept money or any other property from the debtor before the filing fee is paid in full. _____________________________________________ __________________________ Printed or Typed Name of Bankruptcy Petition Preparer Social Security No. (Required by 11 U.S.C. 110(c).) Address: __________________________________________ __________________________________________ Names and Social Security Numbers of all other individuals who prepared or assisted in preparing this document: If more than one person prepared this document, attach additional signed sheets conforming to the appropriate Official Form for each person. Date: _______________________ Signed: _____________________________________ Bankruptcy Petition Preparer A bankruptcy petition preparers failure to comply with thovisions of Title 11 ane prd the Feral Rules of Bankruptcy Procedurdee may result in fines or imprisonment or both. 11 U.S.C. 110; 18 U.S.C. 156. [ver. 1/1/2004 appffecf] American LegalNet, Inc. www.USCourtForms.com