Form B 280 - Disclosure Of Compensation Of Bankruptcy Petition Preparer

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CLEAR FORM

B 280

(10/05)

United States Bankruptcy Court

Southern District Of Iowa

In re _____________________________

Debtor

Case No. ____________

Chapter _____________

DISCLOSURE OF COMPENSATION OF BANKRUPTCY PETITION PREPARER

[Must be filed with the petition if a bankruptcy petition preparer prepares the petition. 11 U.S.C. § 110(h)(2).]

Under 11 U.S.C. § 110(h), I declare under penalty of perjury that I am not an attorney or employee of an attorney, that I prepared

or caused to be prepared one or more documents for filing by the above-named debtor(s) in connection with this bankruptcy case,

and that compensation paid to me within one year before the filing of the bankruptcy petition, or agreed to be paid to me, for

services rendered on behalf of the debtor(s) in contemplation of or in connection with the bankruptcy case is as follows:

For document preparation services I have agreed to accept...............................

$______________

Prior to the filing of this statement I have received.............................................

$______________

Balance Due......................................................................................................... $______________

I have prepared or caused to be prepared the following documents (itemize):

and provided the following services (itemize):

The source of the compensation paid to me was:

Debtor

Other (specify)

The source of compensation to be paid to me is:

Debtor

Other (specify)

The foregoing is a complete statement of any agreement or arrangement for payment to me for preparation of the petition filed

by the debtor(s) in this bankruptcy case.

To my knowledge no other person has prepared for compensation a document for filing in connection with this bankruptcy case

except as listed below:

NAME

SOCIAL SECURITY NUMBER

x___________________________________

______________________________

_________________

Signature

Social Security number of bankruptcy

Date

____________________________________

petition preparer (If the bankruptcy

Printed name and title, if any, of Bankruptcy

petition preparer is not an individual,

Petition Preparer

state the Social Security number of the

Address:_____________________________

officer, principal, responsible person or

partner of the bankruptcy petition preparer.)

____________________________________

(Required by 11 U.S.C. § 110.)

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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.