Application To Pay Filing Fee In Installments (For Cases Filed On Or After 10-17-05)

B3A (Official Form 3A) (11/12) UNITED STATES BANKRUPTCY COURT EASTERN DISTRICT OF VIRGINIA [EDVA 11/12] <Select Div.> In re Debtor(s) Division Case No. Chapter APPLICATION TO PAY FILING FEE IN INSTALLMENTS - EASTERN DISTRICT OF VIRGINIA 1. In accordance with Fed. R. Bankr. P. 1006 and Local Bankruptcy Rule 1006-1, I apply for permission to pay the filing fee amounting to $________________ in installments. 2. 3. 4. ___ I am unable to pay the filing fee except in installments. Until the filing fee is paid in full, I will not make any additional payment or transfer any additional property to an attorney or any other person for services in connection with this case. I propose the following terms for the payment of the Filing Fee. (check applicable Chapter and fill in due dates): __________________, 20___ __________________, 20___ __________________, 20___ __________________, 20___ __________________, 20___ __________________, 20___ __________________, 20___ __________________, 20___ __________________, 20___ __________________, 20___ __________________, 20___ __________________, 20___ Chapter 7: $100.00 upon filing of petition: $100.00 within one month thereafter: $106.00 within two months thereafter: Chapter 11: $430.00 upon filing of petition: $409.00 within one month thereafter: $374.00 within two month thereafter: Chapter l2: $105.00 upon filing of petition: $75.00 within one month thereafter: $66.00 within two months thereafter: ___ ___ Chapter l3: $90.00 upon filing of petition: $90.00 within one month thereafter: $101.00 within two months thereafter: If any installment due date falls on a day that the Court is closed, payment shall be made not later than the next business day. 5. I understand that the clerk shall issue an order of dismissal in any case where the initial installment payment required under FRBP 1006 and Local Bankruptcy Rule 1006-1(B) has not accompanied the filed petition or in any case where a subsequent installment payment has not been received by the due date and the debtor will not receive a discharge. Applicant further understands that upon dismissal of the case, the remaining filing fee is nonetheless due and payable within 14 days following dismissal of the case and that subsequent applications to pay filing fees in installments will be denied until all prior filing fees are paid in full. ___________________________ Signature of Attorney Date ___________________________ Name of Attorney ___________________________ State Bar No. ___________________________ Address ___________________________ Telephone No. ______________________________________________ Signature of Debtor Date (In a joint case, both spouses must sign.) ______________________________________________ Signature of Joint Debtor (if any) Date American LegalNet, Inc. www.FormsWorkFlow.com 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 by 11 U.S.C. § 110, (2) I prepared the accompanying document for compensation and have provided the debtor with a copy of that document and the notices and information required under 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 under that section; and (4) I will not accept any additional money or other property from the debtor before the filing fee is paid in full. _____________________________________________ Printed or Typed Name of Bankruptcy Petition Preparer ____________________________________ Social Security No. (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 the document. Address: __________________________________________ __________________________________________ x________________________________________________ Signature of Bankruptcy Petition Preparer ________________ Date Names and Social Security Numbers of all other individuals 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 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. American LegalNet, Inc. www.FormsWorkFlow.com