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United States Bankruptcy Court


District of _______________________________

In re: ___________________________________

Bankruptcy Case No. ______________________

Debtor __________________________________


1. Pursuant to 11 U.S.C. Sec. 329(a) and Bankruptcy Rule 2016(b), I certify that I am the attorney for the above-named debtor(s) and that compensation paid to me within one year before the filing of the petition in bankruptcy, or agreed to be paid to me, for services rendered or to be rendered on behalf of the debtor(s) in contemplation of or in connection with the bankruptcy case is as follows;


For legal services, I have agreed to accept ________________ dollars ($__________).

Prior to the filing of this statement I have received ______________________ dollars ($__________). The Balance Due is _____________________dollars ($__________).


2. The source of the compensation paid to me was: [ ] Debtor [ ] Other (specify)


3. The source of  compensation to be paid to me is: [ ] Debtor [ ] Other (specify)


4. [ ]    I have not agreed to share the above-disclosed compensation with any other

            person unless they are members and associated of my law firm.

    [ ]    I have agreed to share the above-disclosed compensation with a  person or

              persons who are not members or associates of my law firm.  A copy of the

              agreement, together with a list of the names of the people sharing in the

              compensation is attached.


5. In return for the above-disclosed fee, I have agreed to render legal service for all aspects of the bankruptcy case, including:


a.   Analysis of the debtor’s financial situation, and rendering advice to the debtor in determining whether to file a petition in bankruptcy;


b.   Preparation and filing of any petition, schedules, statement of affairs and plan which may be required;


c.   Representation of the debtor at the meeting of creditors and confirmation hearing and adjourned hearings thereof;


d.  Representation of the debtor in adversary proceedings and other contested bankruptcy matter;


e.   [Other provisions as needed].


6. By agreement with the debtor(s), the above-disclosed fee does not include the following services:











I certify that the foregoing is a complete statement of any agreement or arrangement for payment to me for representation of the debtor(s) in this bankruptcy proceeding.


______________________________      ______________________________

Date                                                                                    Signature of Attorney



                                                                                            Name of Law Firm




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