**UNITED STATES BANKRUPTCY COURT**

**for the**

**Eastern District of Missouri**

**In re Case No. \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_**

**Chapter** [\_\_\_\_\_\_\_\_\_\_\_\_\_\_]{.underline}

**, Debtor**

**APPLICATION TO PAY FILING FEES IN INSTALLMENTS**

In accordance with Federal Rule of Bankruptcy Procedure 1006, I apply
for permission to pay the Filing Fee of \$ in installments, and certify
that I am unable to pay the Filing Fee except in installments. Until the
filing fee is paid in full, I will not make any additional payments or
transfer any additional property to an attorney or any other person for
services in connection with this case.

**[COMPLETE THIS SECTION ONLY IF THIS IS A CHAPTER 13
CASE]{.underline}**

Amount paid at time of filing petition -
\$\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

I will pay the balance of the Filing Fee through my Chapter 13 plan. (In
a Chapter 13 case, any unpaid balance of the filing fee [must be paid
through the Chapter 13 plan]{.underline}. Local Rule of Bankruptcy
Procedure 1006-1 B.)

**[COMPLETE THIS SECTON IF THIS IS NOT A CHAPTER 13 CASE]{.underline}**

I propose the following terms for payment of the Filing Fee.\*

\$\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_ Check one □ With the filing
of the petition □ On or before
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

\$\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_ on or before
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

\$\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_ on or before
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

\$\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_ on or before
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

\* The number of installments proposed shall not exceed four (4), and
the final installment shall be payable not later than 120 days after
filing the petition. For cause shown, the court may extend the time of
any installment, provided the last installment is paid not later than
180 days after filing the petition (Federal Rule of [Bankruptcy
Procedure
1006(b)(2))]{.underline}\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

**[FOR ALL FILERS]{.underline}** - I understand that if I fail to pay
any installment when due my bankruptcy case **[may be
dismissed]{.underline}** without further notice or hearing, and I may
not receive a discharge of my debts. I understand that if I am a Chapter
13 debtor, failure to pay any portion of the filing fee through my
Chapter 13 plan may result in my bankruptcy case being dismissed and I
may not receive a discharge of my debts.

\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

Signature of Attorney Date Signature of Debtor Date

(In a joint case, both spouses must sign)

\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

Name of Attorney Signature of Joint Debtor (if any) Date

**\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_**

**DECLARATION AND SIGNATURE OF NON-ATTORNEY BANKRUPTCY PETITION PREPARER
(See 11 U.S.C. § 110)**

I declare under penalty of perjury that: (1) I am a bankruptcy petition
preparer as defined in 11 U.S.C. § 110; (2) I prepared this document for
compensation and have provided the debtor with a copy of this document
and the notices and information required under 11 U.S.C. §§ 110(b),
110(h), and 342(b); (3) if rules or guidelines have been promulgated
pursuant to 11 U.S.C. § 110(h) setting a maximum fee for services
chargeable by bankruptcy petition preparers, I have given the debtor
notice of the maximum amount before preparing any document for filing
for a debtor or accepting any fee from the debtor, as required under
that section; and (4) I will not accept any additional money or other
property from the debtor before the filing fee is paid in full.

\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

Printed or Typed Name and Title, if any, of Bankruptcy Petition Preparer
Social Security Number (Required by 11 U.S.C. § 110)

*If the bankruptcy petition preparer* *is not an individual, state the
name, title (if any), address, and social security number of the
officer, principal, responsible person, or partner who signs the
document.*

\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

ADDRESS

X \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

Signature of Bankruptcy Petition Preparer Date

Names and Social Security numbers of all other individuals who prepared
or assisted in preparing this document, unless the bankruptcy petition
preparer is not an individual:

***If more than one person prepared this document, attach additional
signed sheets conforming to the appropriate Official Form for each
person.***

***A bankruptcy petition preparer's failure to comply with the
provisions of title 11 and the Federal Rules of Bankruptcy Procedure may
result in fines or imprisonment or both. 11 U.S.C.*** § ***110; 18
U.S.C.*** § ***156.***

> (L.F. 1 Rev. 12/07)