Form 202 Worksheet - Declaration Under Penalty of Perjury for Non-Individual Debtors

Worksheet only. Not the official form. Transfer to Official Form 202 or e-filing software. Use for the listed documents (and any amendments) and have an authorized representative sign.

United States Bankruptcy Court
District of [District]

In re: [Debtor Name]
Case No.: [if known]
Chapter: [7/9/11/12]

Declaration of Representative

• I am the [title/position] of the debtor and authorized to sign this document on behalf of the debtor.
• I have examined the following documents and I have a reasonable belief that the information provided in them is true and correct:
• [ ] Schedule A/B: Assets - Real and Personal Property (Official Form 206A/B)
• [ ] Schedule D: Creditors Who Hold Claims Secured by Property (Official Form 206D)
• [ ] Schedule E/F: Creditors Who Have Unsecured Claims (Official Form 206E/F)
• [ ] Schedule G: Executory Contracts and Unexpired Leases (Official Form 206G)
• [ ] Schedule H: Codebtors (Official Form 206H)
• [ ] Summary of Assets and Liabilities for Non-Individuals (Official Form 206Sum)
• [ ] Amended Schedule ___
• [ ] Chapter 11 or Chapter 9: List of Creditors Who Have the 20 Largest Unsecured Claims and Are Not Insiders (Official Form 204)
• [ ] Other document that requires a declaration (describe): ______________________
• I declare under penalty of perjury that the foregoing is true and correct.

Signature of Authorized Representative of Debtor

• Executed on (MM/DD/YYYY): __________
• Signature: ____________________________
• Printed name: [ ]
• Position or relationship to debtor: [ ]
• Worksheet-only contact (not on Official Form 202): Address/Phone/Email [ ]

Warning: Bankruptcy fraud is a serious crime. 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 $500,000 or imprisonment for up to 20 years, or both. 18 U.S.C. §§ 152, 1341, 1519, and 3571.

Optional aide-memoire (not part of Official Form 202)

• Small business/Subchapter V: confirm recent balance sheet, statement of operations, cash-flow statement, and most recent federal income tax return (or statement that none exist) are attached elsewhere if required.
• Health care business: confirm patient records are secured; ombudsman motion filed if required.
• SEC filer: if applicable, ensure any required SEC-related statement (e.g., Form 201A equivalent) is attached with the petition (not part of this declaration).