FLNB Local Form 18 (Rev. 07/11) UNITED STATES BANKRUPTCY COURT NORTHERN DISTRICT OF FLORIDA GAINESVILLE D In Re: Case No.: Chapter: Debtor(s) MOTION FOR DETERMINATION AND WAIVER OF DEBTOR'S DUTY TO COMPLY WITH THE CREDIT COUNSELING REQUIREMENT UNDER 11 U.S.C. SECTION 109(h)(4) In accordance with Section 109(h)(4) of the Bankruptcy Code, I hereby request that the Court determine that I may be relieved of the credit counseling requirement imposed by Section 109(h)(4) of the Bankruptcy Code due to an incapacity, disability or because I am engaged in active military duty in a military combat zone . For the purposes of making this request under Section 109(h)(4), I understand that "incapacity" means that the debtor is impaired by reason of mental illness or mental deficiency so that he or she is incapable of realizing and making rational decisions with respect to his or her financial responsibilities; and "disability" means that the debtor is so physically impaired as to be unable, after reasonable effort, to participate in an in-person, telephone, or internet briefing as required by statute. My request is based on one of the following (Please check one of the boxes below): I have an incapacity. I have a disability. I am engaged in active military duty in a military combat zone. [In the space provided on the next page, please furnish a detailed explanation setting forth the basis for your request. Attach any documentation that will assist the Court in making a determination. Please do not include any unnecessary private information such as the names of your minor children or your full Social Security Number (include only the last four numbers of your Social Security Number). If both the debtor and joint debtor are making a request under Section 109(h)(4), each debtor should file a separate request with the Court. Please note that this waiver only applies to the debtor making the request. A joint debtor to whom this waiver does not apply must still satisfy the credit counseling requirement .] American LegalNet, Inc. www.FormsWorkFlow.com Explanation: Signature of Attorney Date Name of Attorney Signature of Debtor or Joint Debtor, as applicable Date Name of Debtor or Joint Debtor, as applicable Print Form Reset Form American LegalNet, Inc. www.FormsWorkFlow.com