CASB — CSD 1804 [4/1/2022] Page 1 of 2 (CSD1804)

Source: https://www.casb.uscourts.gov/sites/casb/files/documents/forms/CSD1804.pdf

CSD 1804 [4/1/2022] Page 1 of 2

Name, Address, Telephone No. of Debtor(s)

UNITED STATES BANKRUPTCY COURT SOUTHERN DISTRICT OF CALIFORNIA 325 West F Street, San Diego, California 92101-6991

In Re

BANKRUPTCY NO. (if known):

CHAPTER:

Debtor(s).

DECLARATION RE: ELECTRONIC FILING OF SELF-REPRESENTED INDIVIDUAL

1. I (we) have completed the following documents using the Court’s Electronic Filing Program for self-represented

   debtors:

   Voluntary Petition for Individuals Filing for Bankruptcy Statement of Exemption from Presumption of (Official Form B101) Abuse Under §707(b)(2) (Chapter 7 only) (Official Form B122A-1Supp) Your Statement of Financial Affairs for Individuals Chapter 7 Means Test (Official Form B122A-2) Filing for Bankruptcy (Official Form B107)

   Declaration About an Individual Debtor’s Schedules Chapter 13 Statement of Current Monthly (Official Form B106) Income, Calculation of Commitment Period (Official Form 122C-1) Statement of Intention for Individuals Filing Under Chapter 13 Calculation of Your Disposal Income Chapter 7 (Official Form B108) (Official Form 122C-2)

   Chapter 7 Statement of Your Current Monthly Income Chapter 13 Plan (CSD 1300) (Official Form B122A-1)

2. Declaration of Petitioner:
a. To be completed in all cases.

I (we), the Debtor(s) hereby declare under penalty of perjury that: (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.

I further declare under penalty of perjury that I (we) have completed and signed Your Statement about Your Social Security Number(s) (Official Form B121) 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.

This form is mandatory. It has been approved for use by the United States Bankruptcy Court.

CSD 1804 [4/1/2022] Page 2 of 2

b. To be checked and applicable only if the petitioner is an individual (or individuals) whose debts are primarily consumer debts and who has (or have) chosen to file under chapter 7.

I (we) am (are) aware that I (we) may proceed under chapter 7, 11,12, or 13 of Title United States

Code; I (we) understand the relief available under each such chapter; I (we) choose to proceed under chapter 7; and I (we) request relief in accordance with chapter 7. I (we) am (are) aware that I (we) may proceed under chapter 7, 11,12, or 13 of Title United States Code; I (we) understand the relief available under each such chapter; I (we) choose to proceed under chapter 13; and I (we) request relief in accordance with chapter 13.

I understand that failure to file the signed original of this Declaration is grounds for dismissal of my case pursuant to 11 U.S.C. §§ 707(a) and 105.

SIGN

Date Debtor’s Name Debtor’s Signature

SIGN

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.