Statement Of Debtor As To Assistance By Non-Attorney In Regards To Preparing And Filing Petition

UNITED STATES BANKRUPTCY COURT FOR THE WESTERN DISTRICT OF VIRGINIA ____________________DIVISION In re: CASE NO. Debtor(s) CHAPTER STATEMENT OF DEBTOR AS TO ASSISTANCE BY NON-ATTORNEY IN REGARDS TO PREPARING AND FILING PETITION The above debtor hereby discloses the following information concerning assistance in connection with the filing of this bankruptcy case: ( ) 1) No assistance was provided. ( ) 2) Name, address, social security number, and telephone number of person or firm who provided assistance: __________________________________________________________ __________________________________________________________ __________________________________________________________ __________________________________________________________ 3) Amount Amount paid for same: $_____________________________ 4) Method of payment: _______________________________________ 5) Balance due, if any: $_______________________________________ I declare under penalty of perjury that the foregoing information given in regards to assistance by non-attorney in the filing of this petition is true and co rrect to the best of my information and belief. Executed at _______________________ Executed on _______________________ _______________________________________ Debtor _______________________________________ Joint Debtor soda.frm American LegalNet, Inc. www.USCourtForms.com