Declaration Regarding Electronic Filing {LBF 5005-4}

LBF 5005-4 (Eff. 7/1/19) UNITED STATES BANKRUPTCY COURT DISTRICT OF NEW HAMPSHIRE In re: , Bk. No. -- Debtor Chapter DECLARATION REGARDING ELECTRONIC FILING Part 1 - Declaration of Petitioner/Declarant: I, , the undersigned, hereby declare under penalty of perjury that the information I have given my attorney and the information contained in the document listed below is true and correct to the best of my knowledge and belief. The Notice of Electronic Filing of the document listed below is attached as Exhibit A. Part 2 - Identification of Document: Voluntary Petition, Schedules and Statements consisting of pages. Full Social Security number of debtor: -- Full Social Security number of joint debtor: -- [If petitioner is an individual] I declare under penalty of perjury that the foregoing Social Security number is true and correct. [If petitioner is a corporation, partnership or limited liability entity] I declare under penalty of perjury that the information provided in the petition is true and correct, and that I have been authorized to file the petition on behalf of the debtor. The debtor requests relief in accordance with the chapter specified in the petition. Voluntary Petition consisting of pages. Full Social Security number of debtor: -- Full Social Security number of joint debtor: -- [If petitioner is an individual] I declare under penalty of perjury that the foregoing Social Security number is true and correct. [If petitioner is a corporation, partnership or limited liability entity] I declare under penalty of perjury that the information provided in the petition is true and correct, and that I have been authorized to file the petition on behalf of the debtor. The debtor requests relief in accordance with the chapter specified in the petition. Schedules and Statements consisting of pages. Amendment to Petition, Schedules or Statements consisting of pages. Amendment of Social Security number. Full Social Security number of debtor: -- Full Social Security number of joint debtor: -- Verified Complaint consisting of pages. American LegalNet, Inc. www.FormsWorkFlow.com LBF 5005-4 (Eff. 7/1/19) Chapter 13 Plan or Amended Chapter 13 Plan consisting of pages. Other: [insert name of document] dated , consisting of pages. I understand that this DECLARATION REGARDING ELECTRONIC FILING is to be submitted to the clerk after the above-listed document has been filed electronically but, in no event shall it be submitted later than seven (7) days after the document has been filed. I acknowledge receipt of a copy of the document that is being electronically filed. I understand that failure to submit this DECLARATION to the court is grounds for dismissal of my case and/or grounds for the court to strike the document identified above from the record in this proceeding. I understand that this DECLARATION must contain my handwritten, wet ink signature, which appears below. Date: Signed: Name/Title: Date: Signed: Name/Title: Part 3 - Declaration of Attorney: I declare that, to the best of my knowledge, information and belief, formed after an inquiry reasonable under the circumstances, that the document identified above is not being presented for any improper purpose; that the claims, defenses, allegations and other legal or factual contentions have, or will have, evidentiary support, and that the denials of factual contentions are warranted. I further certify that the petitioner/declarant signed this Declaration and authorized me to electronically file the document identified above, that I gave the petitioner/declarant a copy of the document identified above that is being electronically filed, and that the document identified in the attached Notice of Electronic Filing from the CM/ECF system is the document identified above. I understand that this DECLARATION must contain my handwritten, wet ink signature, which appears below. Date: Attorney Signature Print Name Address Tel. No. NOTE: You must attach the Notice of Electronic Filing as an exhibit. (SUBMIT ORIGINAL TO COURT. DO NOT FILE ELECTRONICALLY.) American LegalNet, Inc. www.FormsWorkFlow.com