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B 203 (12/94)

United States Bankruptcy Court
_______________ District Of _______________
In re Case No. ___________ Debtor Chapter _________

DISCLOSURE OF COMPENSATION OF ATTORNEY FOR DEBTOR
1. Pursuant to 11 U .S.C. § 329(a) and Fed. Bankr. P. 2016(b), I certify that I am the atto rn ey for the abovenamed debtor(s) and that compensation paid to me w ithin one year before the filing of the petition in bankruptcy, o r agreed to be paid to me, fo r services rendered or to be rendered on behalf o f the debto r(s) in contemplation of or in connection w ith the bankruptcy case is as follow s: For legal services, I have agreed to accept . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . $______________ Prior to the fi ling of this statem ent I have recei ved . . . . . . . . . . . . . . . . . . . . . . . . . . . . . $______________ Balance D ue . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . $______________ 2. The source of the compensati on paid to me w as: D ebtor O ther (specify)

3. The source of compensati on to be paid to me is: D ebtor 4. O ther (specify)

I have not agreed to share the above-disclosed compensation w ith any other person unl ess they are members and associates of my law firm. I have agreed to share the above-disclosed compensation w ith a other person or persons w ho are not members or associates of my law firm. A copy of the agreement, together w ith a list of the names of the people sharing in the compensation, is attached.

5. In return for the above-di sclo sed fee, I have agreed to render legal service for all aspects of the bankruptcy case, incl uding: a. Analysis of the debtor' s fi nancial situati on, and renderi ng advice to the debtor i n determining w hether to file a petiti on in bankruptcy; b. Preparation and filing of any petition, schedules, statements of affairs and plan w hich may be required; c. Representati on of the debtor at the meeti ng of cred itors and confi rm ati on heari ng, and any adj ourn ed hearings thereof;

DISCLOSURE OF COMPENSATION OF ATTORNEY FOR DEBTOR (Continued)

d. Representation of the debtor in adversary proceedin gs and other contested bankruptcy matters; e. [Other provisions as needed]

6. By agreem ent w ith the debtor(s), the above-discl osed fee does not i ncl ude the follow ing services:

CERTIFICATIO N

I certify that the foregoing is a complete statement of any agreement or arrangement for paym ent to me for representati on of the debtor(s) in this bankru ptcy p ro ceedings.

___________________________
Date

___________________________________________________
Signature of Attorney

_____________________________________________________________ Name of law firm