DECLARATION REGARDING ELECTRONIC FILING (SELF …

1 UNITED STATES BANKRUPTCY COURT CENTRAL DISTRICT OF CALIFORNIA -- Name of Debtor(s): Debtor(s) CASE NO.: CHAPTER: DECLARATION REGARDING ELECTRONIC FILING (SELF-REPRESENTED INDIVIDUAL) (we) have completed the following documents using the Court s ELECTRONIC Submission program for self-represented debtors(eSR): Petition (Official Form 101) Statement of Related Cases ( ) DECLARATION About an Individual Debtor'sSchedules (Official Form 106 Dec) Statement of Financial Affairs(Official Form 107) Chapter 7 Individual Debtor's Statement ofIntention (Official Form 108) Chapter 7 Statement of Current Monthly Income(Official Form 122A-1) Statement of Exemption from Presumption of AbuseUnder 707 (b)(2) (Official Form 122A- Supp) (if applicable) Chapter 7 Means Test Calculation(Form B 122A-2) (if applicable) Verification of Master Mailing List of Creditors[LBR 1007-1(a)] of be completed in all (we), the undersigned Debtor(s) hereby declare under penalty of perjury that.

2 (1) I(we) have read and understand the above- referenced document(s) being filed electronically ( Voluntary Petition ); (2) the information contained in the petition, statements and schedules, lists, and disclosures is true and correct, to the best of my knowledge and belief; and (3) I (we) have authorized the ELECTRONIC FILING of the Voluntary Petition with the United States Bankruptcy Court for the Central District of California. I further declare under penalty of perjury that I (we) have completed and signed a Statement About Your Social Security Number(s) (Form 1 21) and provided the signed original(s) to the Clerk. I (we) understand that this DECLARATION REGARDING ELECTRONIC FILING must be filed with the Clerk in addition to the petition. be checked and applicable only if the petitioner is an individual (or individuals) whose debts are primarily consumerdebts and who has (or have) chosen to file under chapter 7.

3 I(we) am (are) aware that I(we) may proceed under chapter 7, 11, 12, or 13 of Title 11 United StatesCode; I(we) understand the relief available under each such chapter; I(we) choose to proceed underchapter 7; and I(we) request relief in accordance with chapter understand that failure to file the signed original of this DECLARATION is grounds for dismissal of my case pursuant to 11 707(a) and 105 Date Debtor s Name Debtor s Signature Date Joint Debtor s Name Joint Debtor s Signature This form is mandatory. It has been approved for use by the United States Bankruptcy Court for the Central District of California July 2017 page 1 7 Official Form 121 Statement About Your Social Security NumbersUnited States Bankruptcy Court for the: Central District of CaliforniaCase number (If known): _____ Fill in this information to identify your case: Official Form 121 Statement About Your Social Security Numbers 12/15 Use this form to tell the court about any Social Security or federal Individual Taxpayer Identification numbers you have used.

4 Do not file this form as part of the public case file. This form must be submitted separately and must not be included in the court s public ELECTRONIC records. Please consult local court procedures for submission requirements. To protect your privacy, the court will not make this form available to the public. You should not include a full Social Security Number or Individual Taxpayer Number on any other document filed with the court. The court will make only the last four digits of your numbers known to the public. However, the full numbers will be available to your creditors, the Trustee or bankruptcy administrator, and the trustee assigned to your case. Making a false statement, concealing property, or obtaining money or property by fraud in connection with a bankruptcy case can result in fines up to $250,000, or imprisonment for up to 20 years, or both. 18 152, 1341, 1519, and 3571.

5 Part 1: Tell the Court About Yourself and Your spouse if Your Spouse is FILING With You For Debtor 1: For Debtor 2 (Only If Spouse Is FILING ): 1. Your name_____ First name _____ Middle name _____ Last name _____ First name _____ Middle name _____ Last name Part 2: Tell the Court About all of Your Social Security or Federal Individual Taxpayer Identification Numbers2. All Social SecurityNumbers you haveused__ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ You do not have a Social Security __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ You do not have a Social Security All federal IndividualTaxpayerIdentificationNumbers (ITIN) youhave used9 __ __ __ __ __ __ __ __9 __ __ __ __ __ __ __ __ You do not have an __ __ __ __ __ __ __ __9 __ __ __ __ __ __ __ __ You do not have an 3: Sign Below Under penalty of perjury, I declare that the information I have provided in this form is true and correct.

6 _____Signature of Debtor 1 Date _____MM / DD / YYYY Under penalty of perjury, I declare that the information I have provided in this form is true and correct. _____Signature of Debtor 2 Date _____MM / DD / YYYY Attorney or Party Name, Address, Telephone & FAX Nos., State Bar No. & Email Address FOR COURT USE ONLY Debtor(s) appearing without an attorney Attorney for Debtor(s) UNITED STATES BANKRUPTCY COURT CENTRAL DISTRICT OF CALIFORNIA - DIVISION In re: CASE NO.: CHAPTER: DECLARATION BY DEBTOR(S) AS TO WHETHER INCOME WAS RECEIVED FROM AN EMPLOYER WITHIN 60 DAYS OF THE PETITION DATE[11 521(a)(1)(B)(iv)] [No hearing required] Debtor(s). Debtor(s) provides the following DECLARATION (s) as to whether income was received from an employer within 60 days of the Debtor(s) FILING this bankruptcy case (Petition Date), as required by 11 521(a)(1)(B)(iv): DECLARATION of Debtor 1 am Debtor 1 in this case, and I declare under penalty of perjury that the following information is true and correct:During the 60-day period before the Petition Date (Check only ONE box below):I was paid by an employer.

7 Attached are copies of all statements of earnings, pay stubs, or other p roof of employment income I received from my employer during this 60-day period. (If the Debtor s social security number or bank account is on a pay stub or other proof of income, the Debtor must cross out (redact) the number(s) before FILING this DECLARATION .) I was not paid by an employer because I was either self-employed only, or not employed. Date: _____ _____ Printed name of Debtor 1 Signature of Debtor 1 This form is mandatory. It has been approved for use in the United States Bankruptcy Court for the Central District of California. December 2015 Page 1 F of Debtor 2 (Joint Debtor) (if applicable) am Debtor 2 in this case, and I declare under penalty of perjury that the following information is true and correct:During the 60-day period before the Petition Date (Check only ONE box below):I was paid by an employer.

8 Attached are copies of all statements of earnings, pay stubs, or other proof of employment income I received from my employer during this 60 day period. (If the Debtor s social security number or bank account is on a pay stub or other proof of income, the Debtor must cross out (redact) the number(s) before FILING this DECLARATION .) I was not paid by an employer because I was either self-employed only, or not employed. Date: _____ _____ Printed name of Debtor 2 Signature of Debtor 2 This form is mandatory. It has been approved for use in the United States Bankruptcy Court for the Central District of California. December 2015 Page 2 F Form 119 Bankruptcy Petition Preparer s notice , DECLARATION , and Signaturepage 1 Official Form 119 Bankruptcy Petition Preparer s notice , DECLARATION , and Signature 12/15 Bankruptcy petition preparers as defined in 11 110 must fill out this form every time they help prepare documents that are filed in the case.

9 If more than one bankruptcy petition preparer helps with the documents, each must sign in Part 2. A bankruptcy petition preparer who does not comply with the provisions of title 11 of the United States Code and the Federal Rules of Bankruptcy Procedure may be fined, imprisoned, or both. 11 110; 18 156. Part 1: notice to Debtor Bankruptcy petition preparers must give the debtor a copy of this form and have the debtor sign it before they prepare any documents for FILING or accept any compensation. A signed copy of this form must be filed with any document prepared. Bankruptcy petition preparers are not attorneys and may not practice law or give you legal advice, including the following: whether to file a petition under the Bankruptcy Code (11 101 et seq.); whether FILING a case under chapter 7, 11, 12, or 13 is appropriate; whether your debts will be eliminated or discharged in a case under the Bankruptcy Code; whether you will be able to keep your home, car, or other property after FILING a case under the Bankruptcy Code; what tax consequences may arise because a case is filed under the Bankruptcy Code; whether any tax claims may be discharged; whether you may or should promise to repay debts to a creditor or enter into a reaffirmation agreement; how to characterize the nature of your interests in property or your debts; or what procedures and rights apply in a bankruptcy bankruptcy petition preparer _____ has notified me of Name any maximum allowable fee before preparing any document for FILING or accepting any fee.

10 8 _____Date _____Signature of Debtor 1 acknowledging receipt of this notice MM / DD / YYYY 8 _____Date _____Signature of Debtor 2 acknowledging receipt of this notice MM / DD / YYYY Debtor 1 _____ First Name Middle Name Last Name Debtor 2 _____ (Spouse, if FILING ) First Name Middle Name Last Name United States Bankruptcy Court for the: Central District of California Case number _____ Chapter _____ (If known) Fill in this information to identify the case: 7 Debtor 1 _____ Case number (if known)_____ First Name Middle Name Last Name Official Form 119 Bankruptcy Petition Preparer s notice , DECLARATION , and Signaturepage 2 Part 2: DECLARATION and Signature of the Bankruptcy Petition Preparer Under penalty of perjury, I declare that: I am a bankruptcy petition preparer or the officer, principal, responsible person, or partner of a bankruptcy petition preparer; I or my firm prepared the documents listed below and gave the debtor a copy of them and the notice to Debtor by Bankruptcy PetitionPreparer as required by 11 110(b), 110(h), and 342(b).