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Name, Address and Telephone No. of Attorney(s) (CLERK'S STAMP) Bar No.: Attorney for Debtor(s) Debtor in Pro Per UNITED STATES BANKRUPTCY COURT FOR THE DISTRICT OF STATEMENT OF ATTORNEY FOR PETITIONER PURSUANT TO BANKRUPTCY RULE 2016(b) In re Debtor(s) (List all names, including trade names, used by Debtor(s) within the last six years) CHAPTER CASE NO.: Social Security No. (Debtor) Social Security No. (Joint Debtor) Debtor's Employer's Tax I.D. No.: The undersigned, pursuant to Rule 2016(b), Bankruptcy Rule, states: 1. The undersigned is the attorney for the debtor(s) in this case. 2. The compensation paid or agreed to be paid by the debtor(s) to the undersigned is: a. for legal services rendered or to be rendered in contemplation of and in connection with this case b. prior to filing this statement, debtor(s) have paid c. the unpaid balance due and payable is 3. $ of the filing fee in this case has been paid. $ $ $ 4. The services rendered or to be rendered include the following: a. Analysis of the financial situation, and rendering advice and assistance to the debtor(s) in determining whether to file a petition under Title 11, United States Code. b. Preparation and filing of the petition, schedules of assets and liabilities, statement of affairs, and other documents required by the court. c. Representation of the debtor(s) at the first meeting of creditors. 5. The source of payments made by the debtor(s) to the undersigned was from earnings, wages, and compensation for services performed, and * 6. The source of payments to be made by the debtor(s) to the undersigned for the unpaid balance remaining, if any, will be from earnings, wages, and compensation for services performed, and 7. The undersigned have not shared or agreed to share, with any other person, other than with members of their law firm or corporation, any compensation paid or to be paid, except as follows: Dated: * If a fee is paid by transfer of property or if security is taken, give details here and in appropriate section of Schedules or Statement of Affairs. Attorney(s) for Debtor(s) BK-2016 2002 © American LegalNet, Inc. Rule 2016(b) - Rev. 4/91