Application Form To Pay Filing Fee In Installments printable pdf download

United States Bankruptcy Court

_______________ District Of ______________

In re _______________________________________, Case No. ___________________

Debtor

Chapter ____________

APPLICATION TO PAY FILING FEE IN INSTALLMENTS

1. In accordance with Fed. R. Bankr. P. 1006, I apply for permission to pay the filing fee amounting to

$_____________in installments.

2. I am unable to pay the filing fee except in installments.

3. Until the filing fee is paid in full, I will not make any additional payment or transfer any additional property to an

attorney or any other person for services in connection with this case.

4. The filing fee is to be paid, in accordance with General Order 32, in full on or before the date first set for the 341(a)

meeting.

5. I understand that if I fail to pay any installment when due, my bankruptcy case may be dismissed and I may not

receive a discharge of my debts.

Signature of Attorney Date

Signature of Debtor

Date

(In a joint case, both spouses must sign.)

Name of Attorney

Signature of Joint Debtor (if any) Date

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DECLARATION AND SIGNATURE OF NON-ATTORNEY BANKRUPTCY PETITION PREPARER (See 11 U.S.C. § 110)

I declare under penalty of perjury that: (1) I am a bankruptcy petition preparer as defined in 11 U.S.C. § 110; (2) I prepared this

document for compensation and have provided the debtor with a copy of this document and the notices and information required

under 11 U.S.C. §§ 110(b), 110(h), and 342(b); (3) if rules or guidelines have been promulgated pursuant to 11 U.S.C. § 110(h)

setting a maximum fee for services chargeable by bankruptcy petition preparers, I have given the debtor notice of the maximum

amount before preparing any document for filing for a debtor or accepting any fee from the debtor, as required under that section;

and (4) I will not accept any additional money or other property from the debtor before the filing fee is paid in full.

____________________________________________

__________________________

Printed or Typed Name and Title, if any, of Bankruptcy Petition Preparer

Social Security No. (Required by 11 U.S.C. § 110.)

If the bankruptcy petition preparer is not an individual, state the name, title (if any), address, and social security number of the

officer, principal, responsible person, or partner who signs the document.

________________________________

Address

x__________________________________________________ _____________________

Signature of Bankruptcy Petition Preparer Date

Names and Social Security numbers of all other individuals who prepared or assisted in preparing this document, unless the

bankruptcy petition preparer is not an individual:

If more than one person prepared this document, attach additional signed sheets conforming to the appropriate Official Form for

each person. A bankruptcy petition preparer’s failure to comply with the provisions of title 11 and the Federal Rules of

Bankruptcy Procedure may result in fines or imprisonment or both. 11 U.S.C. § 110; 18 U.S.C. § 156.

Application Form To Pay Filing Fee In Installments