LF 2014 U N I TE D S TA T E S B A N K R U PT C Y C O UR T E A S T E R N D IS T R IC T O F W A S H I N G T O N Application for Order Approving Employment Case Name Case Number Comes now the undersigned (Trustee/Debtor in Possession/Chairman of the Creditors' Committee) and applies to the court for an order approving the employment of (Appointee) as (Position) for the ( Trustee - Debtor in Possession - Creditors' Committee) in the above entitled estate. For purposes of this application and verification and the disclosures contained herein, the term APPO INTEE shall include the named appointee, and if the named appointee is a law partnership or corporation or an accounting partnership or corporation, or is an attorney or accountant employed as a partner, member, or regular associate of a partnership or corporation, the named appointee and each member, partner or regular associate of such partnership or corporation. Applicant and Appointee in making and verifying this application understand that appointee is a fiduciary to the estate or creditors' committee as appropriate, and is obligated to fully and candidly disclose all material facts relating to the employmen t and is ob ligated to timely disclose su bsequently disco vered material facts. Your applicant makes the following representations under penalty of perjury and subject to 18 U.S.C. § 152: 1. 2. 3. 4. 5. That the specific facts showing the necessity for the employmen t are: That the rea son for the selection of the abov e named a ppointee is: That the pro fessional services to be rendered are: That ap pointee is qualified to provide the services to be rendered b ased on the follow ing: That any proposed arrangement as to compensation, including hourly rates or flat fees if app licable, is as follows, but that approval of that arrangement and any payment or allowance of compensation for serv ices rendered or reimbursement of expe nses will be in accordance w ith 11 U.S.C. §§ 3 29 and 330 an d FR BP 2 016: That appo intee is a rela tive o f the b ankruptcy ju dge assign ed th e case. YES NO 6. 7. (Fo r Trustee or D ebto r in Possession) Tha t app ointe e does hold or re present a n interest a dve rse to the estate, that app ointe e is not a disinterested person, or th at appo intee has ser ved as exa miner in the case. YES NO If YES, explain: (For Creditors' Committee) That appointee is not and will not while employed by the committee represent any other entity having an adverse interest in connection with the case. YES NO If YES, explain: That to best of your applicants knowledge, all of the appointees connections with the debtor, creditors, any other party in interest, their respective attorneys and accountants, the United States Trustee, any person employed in the office of the Un ited States Trustee or the b ankru ptcy ju dge a ssigned th e case are as follow s: A. That appointee is a creditor as defined by 11 U.S.C. § 101(10). following: Da te on any waiver, set-o ff or assignm ent: . Type of debt incurred: Date incurred: Amount incurred: B. YES NO If YES, complete the 8. 9. $ Paym ent made: Date paym ent made: Am oun t of pa ym ent: Rem aining Balance: YES $ $ $ That appointee is indebted to the debtor or to the estate? NO If YES, complete the following: American LegalNet, Inc. www.FormsWorkFlow.com Type of debt incurred: Date incurred: Amount incurred: C. $ Paym ent made: Date paym ent made: Am oun t of pa ym ent: Rem aining Balance: $ $ $ That appointee has or presently represents an entity that could be classified as a creditor as defined by 11 U.S.C. § 101(10)? YES NO If YE S, pro vide th e following and any other releva nt info rm ation as to each such entity: a) name b) dates, capacity and scope of representation c) actual or possible conflicts according to any applicable code or rules of professional conduct, including discussion as to any waivers received or given That appointee is or has been an equity security holder as defined in 11 U.S.C. § 101(17)? YES NO If YE S, pro vide th e following and any other releva nt info rm ation as to su ch eq uity security interests: a) description of ea ch interest b) amo unt of each interest c) da tes ea ch interest held d) date s and m anne r of dispo sal of each interest That ap pointee has or presen tly represents an equity security holder as defined b y 11 U .S.C. § 101(17 )? YES NO If YE S, pro vide th e following and any other releva nt info rm ation as to each such equity security hold er: a) name of holder b) dates, capacity and scope of representation c) actual or possible conflicts according to any applicable code or rules of professional conduct, including discussion as to any waivers received or given. That appointee is or has been an insider as defined by 11 U.S.C. § 101(31)? explain and provide any and all relevant information pertaining thereto. YES NO If YE S, fully D. E. F. G. That appointee has or presently represents an insider as defined by 11 U.S.C. § 101(31)? YES NO If YES , provide the following and a ny other relevant inform ation pe rtaining thereto as to eac h such insider: a) name b) dates, capacity and scope of representation c) actual or possible conflicts according to any applicable code or rules of professional conduct, including discussion as to any waivers received or given. H. That appointee has or presently represents the debtor? and any other relevant information pertaining thereto: a) name b) dates, capacity and scope of representation YES NO If YES, provide the following c) actual or possible conflicts according to any applicable code or rules of professional conduct, including any discussion as to any waivers received or given. I. That appointee has had or has participated in any transaction with the debtor, whether or not such transaction involved representation of the debtor? Transactions include, but are not limited to any actions unde r 11 U .S.C. § 329(a ) and F RB P 20 17(a ), involving paym ents, retainers, set-offs, security agre ements, liens, gifts or indentures as defined by 11 U.S.C. § 101(28). YES NO If YES, provide the following and any other relevant information concerning each such transaction: a) names of all parties involved b) dates and description c) am oun ts invo lved if app licable d) reason for transaction Application for Order Approving Employment 2 American LegalNet, Inc. www.FormsWorkFlow.com J. That appointee has received or has been promised compensation from debtor or some other entity for services rend