B2800, Disclosure of Compensation of Bankruptcy Petition Preparer

This form is for the use of bankruptcy petition preparer. This form functions as a disclosure statement regarding the preparer’s compensation for the services s/he rendered to the debtor prior the start of the bankruptcy case proceeding.Download

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B2800 (Form 2800) (12/15) 	
United States Bankruptcy Court	 	
_______________ District Of ________________  	 	
 
In re _______________________________________________    Case No. ____________  
   Debtor         
          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).]  
    
1.   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 agr eed to accept............................... $______________  
 
Prior to the filing of this statement I have received.............................................  $______________  
 
Balance Due.........................................................................................................  $______________  
 
2.   I have prepared or caused to be prepared the following documents (itemize):  
 
and provided the following services (itemize):  
 
3.   The source of the compensation paid to me was:  
   Debtor        Other (specify)  
 
4.   The source of compensation to be paid to me is:  
   Debtor        Other (specify)  
 
5.   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.  
 
6.   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  
 
 
 
________________________________  _  ______________________________  _________________  
  Signature     Social Security number of bankruptcy   Date 
       petition preparer*   
________________________________  ___________________________________________________	
 	
Printed name and title, if any, of      Address 
Bankruptcy Petition Preparer     	
  
       	 	
 
* If the bankruptcy petition preparer is not an individual, state the Social Security number of the officer, principal, 
responsible person or partner of the bankruptcy petition preparer.   (Required by 11 U.S.C. § 110). 
 
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.