UNITED STATES BANKRUPTCY COURT EASTERN DISTRICT OF VIRGINIA Richmond Division In re Case Number: Debtor(s) DISCLOSURE OF COMPENSATION OF ATTORNEY FOR DEBTOR IN A CHAPTER 13 CASE (for use in the Richmond Division only) 1. Pursuant to 11 U.S.C. 247 329(a) and Bankruptcy Rule 2016(b), I certify that I am the attorney for the above-named debtor(s) and that compensation paid to me, for services rendered or to be rendered on behalf of the debtor(s) in contemplation of or in connection with the bankruptcy case, is as follows: For legal services, I have agreed to accept205205205205205205205205205205205205205205205205205205205205 $ Prior to the filing of this statement I have received205205205205205205..205205205205205205205205205 205.$ Balance Due205205205205205205205205205205205205205205205205205205205205205205205205205205205205205205 205...$ 2. The source of the compensation paid to me was: Debtor Other (specify) 3. The source of compensation to be paid to me is: Debtor Other (specify) 4. I have not agreed to share the above-disclosed compensation with any other person unless they are members and associates of my law firm. I have agreed to share the above-disclosed compensation with a person or persons who are not members or associates of my law firm. A copy of the agreement, together with a list of the names of the people sharing in the compensation, is attached. 5. In return for the above-disclosed fee, I have agreed to render legal service for all aspects of the bankruptcy case, as required by Local Bankruptcy Rule 2016-1(C)(3). 6. I am electing to request compensation and reimbursement of expenses in this case: a. In accordance with the 223no-look224 fee set forth in Local Bankruptcy Rule 2016-1(C)(1)(a) and (C)(3)(a). b. By submitting applications for compensation in the manner set forth in Local Bankruptcy Rule 2016-1(C)(1)(c)(ii). An attorney for the debtor that fails to make the election to request compensation pursuant to Local Bankruptcy Rule 2016-1(C)(1)(a) and (C)(3)(a) at the commencement of the case will be deemed to have elected to request compensation in the manner set forth within Local Bankruptcy Rule 2016-1(C)(1)(c)(ii). American LegalNet, Inc. www.FormsWorkFlow.com 2 CERTIFICATION I certify that the foregoing is an accurate statement of any agreement or arrangement for payment to me for representation of the debtor(s) in this bankruptcy proceeding. Date Signature of Attorney Name of Law Firm NOTICE TO DEBTOR(S), STANDING CHAPTER 13 TRUSTEE AND UNITED STATES TRUSTEE PURSUANT TO LOCAL BANKRUPTCY RULE 2016-1(C) AND CLERK222S CM/ECF POLICY 9 Notice is hereby given that pursuant to Local Bankruptcy Rule 2016-1(C), you must file an objection with the court to the fees requested in this disclosure of compensation opposing said fees in their entirety, or in a specific amount, no later than the last day for filing objections to confirmation of the chapter 13 plan. PROOF OF SERVICE The undersigned hereby certifies that on this date the foregoing Notice was served upon the debtor(s), the standing Chapter 13 trustee, and U. S. trustee pursuant to Local Bankruptcy Rule 2016-1(C) and the Clerk222s CM/ECF Policy 9, either electronically or in paper form (first class mail). Date Signature of Attorney [2030R13edva ver. 12/15] American LegalNet, Inc. www.FormsWorkFlow.com