Declaration Concerning Debtors Amendments To Petition Lists Schedules And-Or Statements

Attorney or Party Name, Address, Telephone and Fax Number, and IASBID No. FOR COURT USE ONLY Attorney for UNITED STATES BANKRUPTCY COURT SOUTHERN DISTRICT OF IOWA In re: CHAPTER _____________ CASE NO. _____________________ Debtor(s) DECLARATION CONCERNING DEBTOR'S AMENDMENTS TO PETITION, LISTS, SCHEDULES AND/OR STATEMENTS I, declare under penalty of perjury that I have read the foregoing summary and schedules consisting of _____________ sheets, and that they; are true and correct to the best of my knowledge, information and belief. Date: Signature:_________________________________________ Debtor Date: Signature:_________________________________________ Joint Debtor (if any) -OR_________________________________________________ Print/Type name of individual signing on behalf of partnership or corporation _________________________________________________ Position or Relationship to Debtor Date: Signature:________________________________________ Penalty for making a false statement or concealing property: Fine of up to $500,000 or imprisonment for up to 5 years or both. 18 U.S.C. § 152 and 3571. IASB ­ DCL AMDMTS [4/14/00] American LegalNet, Inc. www.FormsWorkFlow.com