Form B 3a - Application To Pay Filing Fee In Installments

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B 3A (Official Form 3A) (12/07)

NITED

TATES

ANKRUPTCY

OURT

__________ District Of __________

In re _______________________________________,

Case No. ___________________

Debtor

Chapter ____________

APPLICATION TO PAY FILING FEE IN INSTALLMENTS

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

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

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.

I propose the following terms for the payment of the Filing Fee.*

$ _____________________

Check one

With the filing of the petition, or

On or before ______________

$ _____________________ on or before ________________________________________

The number of installments proposed shall not exceed four (4), and the final installment shall be payable not later than 120 days after filing the

petition. For cause shown, the court may extend the time of any installment, provided the last installment is paid not later than 180 days after filing

the petition. Fed. R. Bankr. P. 1006(b)(2).

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

-------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------

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.