UNITED STATES BANKRUPTCY COURT SOUTHERN DISTRICT OF W EST VIRGINIA In re: __________________________________________(Debtor) Case No. ________________ __________________________________________(Joint Debtor) Chapter ____ Debtor(s). DECLARATION RE: ELECTRONIC FILING AND STATEM ENT OF SOCIAL SECURITY NUM BER(S) (or other Individual Taxpayer-Identification Number(s) (ITIN(s)))* PART I - DECLARATION OF PETITIONER(S): I [We] ____________________________ and __________________________, the undersigned debtor(s), corporate officer, partner, or member, hereby declare under penalty of perjury that the information I have given or will give my attorney and the information provided in the electronically filed petition, statements and schedules is true and correct. I consent to my attorney sending my petition, this declaration, statements and schedules and any future amendments of these documents to the United States Bankruptcy Court, United States Trustee and Panel Trustee. I understand that this Declaration Re: Electronic Filing and Statement of Social Security Number(s) is to be filed with the Clerk after the petition has been filed electronically but, in any event, no later than five (5) business days after the petition has been filed. I [We] hereby designate my attorney, whose signature, name, address, West Virginia State Bar No., telephone and fax numbers are set forth below, as my agent to receive service of process and service of all pleadings in all proceedings, including adversary actions and contested matters, pursuant to Bankruptcy Rule 7004(b)(8), in this Court arising in this case. This designation shall expire upon entry of the final decree. [If petitioner is an individual and has chosen to file under chapter 7, 11, 12 or 13] I am aware that I may proceed under chapter 7, 11, 12, or 13 of 11 United States Code, understand the relief available under each such chapter, and choose to proceed under chapter ______. I request relief in accordance with the chapter specified in the petition. [If petitioner is an individual] __________________________________(Name of debtor): (Check the appropriate box and, if applicable, provide the required information.) G has a Social Security Number and it is: _______- _____- ________ (if more than one, state all.) G does not have a Social Security Number but has an Individual Taxpayer-Identifcation Number (ITIN) and it is: _______- _____- ________ (if more than one, state all.) G does NOT have either a Social Security Number or an Individual Taxpayer-Identification Number (ITIN). __________________________________(Name of joint debtor): (Check the appropriate box and, if applicable, provide the required information.) G has a Social Security Number and it is: _______- _____- ________ (if more than one, state all.) G does not have a Social Security Number but has an Individual Taxpayer-Identifcation Number (ITIN) and it is: _______- _____- ________ (if more than one, state all.) G does NOT have either a Social Security Number or an Individual Taxpayer-Identification Number (ITIN). Signed: ________________________________________________________________________________ (Debtor)(Date) Signed: _________________________________________________________________________________ (Joint Debtor)(Date) [If petitioner is a corporation, partnership or limited liability entity] I declare under penalty of perjury that the information provided in this petition is true and correct, and that I have been authorized to file this petition on behalf of the debtor. The debtor requests relief in accordance with the chapter specified in this petition. Signed: __________________________________________________________________________________ (Authorized Corporate Officer, Partner, or Member)(Date) American LegalNet, Inc. www.FormsWorkflow.com PART II - DECLARATION OF ATTORNEY: I declare under penalty of perjury that I have reviewed the above debtor’s[s’] petition, schedules, and statements and certify that the information is complete and correct to the best of my ability and as I have been informed by the debtor(s). The debtor(s) reviewed these schedules and signed the Declaration Re: Electronic Filing and Statement of Social Security Numbers(s) before I submitted the petition, schedules and statements for filing. I will give the debtor(s) a copy of all pleadings and information to be filed with, or received from, the United States Bankruptcy Court, and have complied with all other requirements in General Order 03-01, the Administrative Procedures for Filing, Signing, and Verifying Pleadings and Papers by Electronic Means, or subsequent amendments to the Administrative Procedures, and this Court’s Local Rules. If this is an individual, I have informed the petitioner(s) that he and/or she may proceed under chapter 7, 11, 12 or 13 of Title 11, United States Code, and have explained the relief available under each such chapter. This declaration is based upon all information of which I have knowledge. Dated: ________________________Signed: ________________________________________ Signature of Attorney for Debtor(s) W V State Bar # Attorney Address/E-mail Address: Attorney Phone No./Fax No.: (FILE ORIGINAL W ITH THE COURT – DO NOT FILE ELECTRONICALLY) American LegalNet, Inc. www.FormsWorkflow.com