Local Form 2016A (9/99)UNITED STATES BANKRUPTCY COURTEASTERN DISTRICT OF WASHINGTONCase Name: Case Number: STATEMENT OF MONEY OR PROPERTY RECEIVED OR PROMISEDIN CONNECTION WITH THIS CASE OTHER THAN BY APPLICATION OR A PLANName of Applicant:Position of Applicant:Application Number:No Money or property was received or promised other than by application as a part of a Chapter 13Plan.(a)Money or things of value received other than by application or as part of a Chapter 13 Plan:(1)Amount received by attorney or firm for filing fee$(2)Amount received before the order for relief byattorney or firm for services and costs$(3)Amount received after the order for relief byattorney or firm for services and costs$(4)Value of any property or service given to attorneyor firm as payment of fees and costs$Description:(5)Total of entries 1, 2, 3 and 4$(6)Amount remaining in client trust account$(b)Amount applied to filing fee and services$(Subtract entry (a)(6) from entry (a)(5))(c)Money promised:$Nature of arrangement for promise of payment:(d)Total amount and value of all money or property received or promisedother than by Application or a Chapter 13 Plan (items (a)(5) and (c))$(e)Other Items (Value and description of any liens, guarantees,security interests or promissory notes):(f)Source of Payment of Promise (If other than the debtor, identify entity and relationship to the debtor):STATEMENT OF MONEY OR PROPERTY RECEIVED American LegalNet, Inc. www.FormsWorkFlow.com