Application To Pay Filing Fees In Installments

UNITED STATES BANKRUPTCY COURT

for the

Eastern District of Missouri

In re

Case No.

Chapter

, Debtor

APPLICATION TO PAY FILING FEES IN INSTALLMENTS

In accordance with Federal Rule of Bankruptcy Procedure 1006, I apply for permission to pay the Filing Fee of $

in installments, and certify that 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 payments or transfer any additional property to

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

COMPLETE THIS SECTION ONLY IF THIS IS A CHAPTER 13 CASE

Amount paid at time of filing petition - $ ____________________

I will pay the balance of the Filing Fee through my Chapter 13 plan. (In a Chapter 13 case, any unpaid balance of the filing fee must be paid through the Chapter 13

plan. Local Rule of Bankruptcy Procedure 1006 B.)

COMPLETE THIS SECTION IF THIS IS NOT A CHAPTER 13 CASE

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

G

$____________________ (Check One)

With the filing of the petition

On or before ______________________________

$____________________ on or before ______________________________

$____________________ 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 (Federal Rule of

Bankruptcy Procedure 1006(b)(2))________________________________________________________________________________________________________

FOR ALL FILERS - I understand that if I fail to pay any installment when due my bankruptcy case may be dismissed without further notice or hearing, and I may

not receive a discharge of my debts. I understand that if I am a Chapter 13 debtor, failure to pay any portion of the filing fee through my Chapter 13 plan may result

in my bankruptcy case being dismissed and I may not receive a discharge of my debts.

Signature of A ttorney

D ate

Signature of D ebtor

D ate

(In a joint case, both spouses m ust sign)

N ame of A ttorney

Signature of Joint Debtor (if any)

D ate

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 Number (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 m ore than one person prepared this docum ent, attach additional signed sheets conform ing to the appropriate O fficial F orm for each person.

A bankruptcy petition preparer’s failure to com ply w ith the provisions of title 11 and the F ederal R ules of B ankruptcy Procedure m ay result in fines or im prisonm ent or both. 11 U .S.C . §

110; 18 U .S.C . § 156.

(L.F. 1 Rev. 06/08)