Declaration and Signature of Non-Attorney Bankruptcy Petition Preparer (See 11 U.S.C. § 110)

In the case of wanting to declare a non-attorney bankruptcy, the following form has to be completed and submitted to the court responsible for making that decision.

Extracted Text for Proper Search

B19 (Official Form 19) (12/07)	
United States Bankruptcy Court	
             _____ District Of _______________	
In re _______________________________, Case No. _________________ 
                                           DebtorChapter ______________	
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 the accompanying document(s) listed below for compensation
and have provided the debtor with a copy of the document(s) and the attached notice as required
by 11 U.S.C. §§ 110(b), 110(h), and 342(b); and (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 by that section.	
Accompanying documents:
___________________________________
___________________________________
___________________________________
___________________________________
___________________________________ Printed or Typed Name and Title, if any, of
Bankruptcy Petition Preparer:
                                                         	
Social-Security No. of Bankruptcy Petition
Preparer (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
this document.
_________________________________
_________________________________
Address
X _______________________________ ____________________
Signature of Bankruptcy Petition Preparer Date 
Names and social-security numbers of all other indi viduals 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 fa ilure 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.

B19 (Official Form 19) (12/07) - Cont.	2	
NOTICE TO DEBTOR BY NON-ATTORNEY BANKRUPTCY PETITION PREPARER
[Must be filed with any document(s) pr epared by a bankruptcy petition preparer.]
I am a bankruptcy petition preparer.  I am not an attorney and may not practice law or give
legal advice.  Before preparing any document for filing as defined in § 110(a)(2) of the Bankruptcy
Code or accepting any fees, I am required by la w to provide you with this notice concerning
bankruptcy petition preparers.  Under the law, § 110 of the Bankruptc\
y Code (11 U.S.C. § 110), I am
forbidden to offer you any legal advice, including advice about any of the following:
• whether to file a petition under the Bankruptcy Code (11 U.S.C. § 101\
 et seq.);
• whether commencing a case under chapter 7, 11, 12, or 13 is appropriate;
• whether your debts will be eliminated or discharged in a case under the Bankruptcy Code;
• whether you will be able to retain your home, car, or other property after commencing a case under the Bankruptcy Code;
• the tax consequences of a case brought under the Bankruptcy Code;
• the dischargeability of tax claims;
• whether you may or should promise to repay debts to a creditor or enter into a reaffirmation agreement with a creditor to reaffirm a debt;
• how to characterize the nature of your interests in property or your debts; or
• bankruptcy procedures and rights.
[The notice may provide additional examples of le gal advice that a bankruptcy petition preparer is
not authorized to give.]
In addition, under 11 U.S.C. § 110(h), the Suprem e Court or the Judicial Conference of the
United States may promulgate rules or guidelines setting a maximum allowable fee chargeable by a
bankruptcy petition preparer.  As required by law,  I have notified you of this maximum allowable
fee, if any, before preparing any document for filing or accepting any fee from you.
____________________________________ _______________________________
Signature of Debtor                     Date Joint Debtor (if any)            Date
[In a joint case, both spouses must sign.]