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UNITED STATES BANKRUPTCY COURT

MIDDLE DISTRICT OF FLORIDA

TAMPA DIVISION

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In re: Case No.: 8:xx-bk-xxxxx-CPM

Chapter: 11 [alternatively, if applicable,

Small Business Chapter 11 Case]

Debtor

Joint Debtor

Debtors.

_____________________________/

DECLARATION OF PAYMENT OF QUARTERLY FEES

FOR CALENDAR YEAR _______

CALENDAR QUARTER ENDING (CHECK ONE)

MARCH 31___JUNE 30___SEPTEMBER 30___DECEMBER 31___OTHER___FINAL___

Total Disbursements for Quarter[1] $__________________________

Quarterly Fees Owed Pursuant to 28 U.S.C. § 1930(a)(6) $__________________________

Quarterly Fees Paid (Attach proof of payment) $__________________________

Date of Payment ___________________________

In accordance with 28 U.S.C. § 1746, I declare under penalty of perjury and under the laws of the United States that I have read and certify that the figures, statements, disbursements, itemizations, and payments as stated above are true and correct.

Executed on:_____________________

_____________________________Signature

Debtor In Possession [trustee]

__________________________Printed Name

___________________________Address

___________________________

___________________________Phone

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[1] Total Disbursements for Quarter should total the same as disbursements indicated on the filed financial monthly operating reports or post-confirmation quarterly reports filed in the case respective to the applicable quarterly fee assessment period.

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