Form 119 Worksheet - Bankruptcy Petition Preparer’s Notice, Declaration, and Signature
Worksheet only. Not the official form. For use when a bankruptcy petition preparer (non-attorney) assists with documents. Transfer to Official Form 119 or e-filing software. Petition preparers must comply with 11 U.S.C. §110.
United States Bankruptcy Court
District of [District]
In re: [Debtor Name(s)]
Case No.: [if known]
Chapter: [7/11/13]
Check if amended filing: [ ]
Part 1: Notice to Debtor from Petition Preparer (acknowledgment)
- Preparer provided copies of all documents prepared for filing? [Yes/No]
- Preparer explained they are not an attorney and may not give legal advice, including:
- whether to file, which chapter, or exemptions to claim;
- whether debts will be discharged or tax treatment;
- whether property will be surrendered or retained;
- how to characterize income, expenses, assets, or debts;
- procedures or rights in the case (reaffirmation, redemption, dischargeability, discharge scope).
- Preparer informed debtor of any maximum allowable fee (if applicable)? [Yes/No]
- Debtor signatures (acknowledgment):
- Debtor 1: __________________ Date: __________
- Debtor 2 (if joint): __________________ Date: __________
Part 2: Declaration and Signature of Petition Preparer
Identify the documents prepared and declare compliance (this declaration is part of each document checked):
- Documents prepared (check all that apply):
- [ ] Voluntary Petition (Official Form 101)
- [ ] Schedule A/B
- [ ] Schedule C
- [ ] Schedule D
- [ ] Schedule E/F
- [ ] Schedule G
- [ ] Schedule H
- [ ] Schedule I
- [ ] Schedule J and J-2 (if applicable)
- [ ] Summary/106Sum
- [ ] Declaration About Schedules (106Dec)
- [ ] Statement of Financial Affairs (107)
- [ ] Form 103A (installments)
- [ ] Form 103B (fee waiver)
- [ ] Form 121 (SSN)
- [ ] Form 122A/122C series
- [ ] Form 108 (Statement of Intention)
- [ ] Creditor/mailing matrix
- [ ] Other (list): ______________________
Preparer declaration (11 U.S.C. §110):
- Preparer name: [ ]
- Preparer address/phone/email: [ ]
- If a business: firm name/address: [ ]
- I declare under penalty of perjury that I am a bankruptcy petition preparer as defined in 11 U.S.C. §110, that I provided the notice above before preparing documents or accepting compensation, and that the information in this declaration is true and correct. If the preparer is not an individual and not a sole proprietor, an officer, principal, responsible person, or partner must sign.
Preparer Signature (include SSN after signature): __________________________ SSN: [###-##-####] Date: __________
Preparer name (printed): [ ]
If more than one preparer:
Preparer 2 name: [ ]
Preparer 2 address/phone/email: [ ]
Preparer 2 Signature (include SSN after signature): __________________________ SSN: [###-##-####] Date: __________
Important compliance reminder
- A signed Form 119 must be filed with any document prepared by a petition preparer.
- If compensation was paid, file the required disclosure (e.g., Director’s Form 2800) separately.
- Preparer must place their identifying information on every document prepared and comply with §110 prohibitions and disclosures.