Official Form 106Dec - Declaration About an Individual Debtor’s Schedules

Worksheet only. File the official Form 106Dec with the completed schedules and 106 Summary. Keep full SSNs off this worksheet; use Official Form 121 for SSNs.

United States Bankruptcy Court
District of [District]

In re: [Debtor Name(s)]
Case No.: [if known]
Chapter: [7/11/13]

Declaration

I declare under penalty of perjury that I have read the summary and schedules filed with this declaration and that they are true and correct to the best of my knowledge, information, and belief.

Debtor 1 Signature: __________________________ Date: __________
Printed Name: [Name]

Debtor 2 Signature (if joint case): __________________________ Date: __________
Printed Name: [Name]

Unpaid Filing Fee (if applicable)

• Amount of filing fee unpaid: $[Amount].
• Paying fee in installments? [Yes/No] (complete Official Form 103A).
• Requesting fee waiver? [Yes/No] (complete Official Form 103B, if eligible).

Attorney or Bankruptcy Petition Preparer Certification

If an attorney prepared these documents, the attorney certifies that an explanation of the schedules and summary was provided and that the debtor signed them before filing.

Attorney Name/Bar No.: [Name, Bar No.]
Firm/Address/Phone/Email: [Details]
Signature: __________________________ Date: __________

Bankruptcy Petition Preparer (if any)
Name/Address: [ ]
Certification of compliance with 11 U.S.C. §110; fee disclosed.
Signature: __________________________ Date: __________

Penalty for making a false statement: fines up to $500,000 or imprisonment for up to 20 years, or both. 18 U.S.C. §§152, 1341, 1343, 1519, and 3571.