Local Form 6 (03/16) (page 1) UNITED STATES BANKRUPTCY COURT MIDDLE DISTRICT OF LOUISIANA IN RE: _____________________________________ DEBTOR CASE NO: ________________ CHAPTER 13 DEBTOR'S CERTIFICATIONS REGARDING DOMESTIC SUPPORT OBLIGATIONS, SECTION 522(q) AND REQUEST FOR ENTRY OF DISCHARGE Any objection to this verification must be filed within 21 days after service of this verification. If no party files an objection, the court may grant a discharge pursuant to 28 U.S.C. § 1328(a) without further notice or a hearing. If this is a joint case, both debtors must complete a separate certification. The debtor moves for entry of a discharge under Bankruptcy Code § 1328(a). Part I. Certification Regarding Domestic Support Obligations (check no more than one) Pursuant to 11 U.S.C. Section 1328(a), I certify that: I owed no domestic support obligation when I filed my bankruptcy petition, and I have not been required to pay any such obligation since then. I am or have been required to pay a domestic support obligation. I have paid all such amounts that my chapter 13 plan required me to pay. I have also paid all such amounts that became due between the filing of my bankruptcy petition and today. Part II. If you checked the second box, you must provide the information below. My current address: ______________________________________________________ ______________________________ My current employer and my employer's address: ________________________________________________________________________ Part III. Certification Regarding Section 522(q) (check no more than one) Pursuant to 11 U.S.C. Section 1328(h), I certify that: I have not claimed an exemption pursuant to § 522(b)(3) and state or local law (1) in property that I or a dependent of mine uses as a residence, claims as a homestead, or acquired as a burial plot, as specified in § 522(p)(1), and (2) that exceeds the amount specified in §522(q)(1). American LegalNet, Inc. www.FormsWorkFlow.com Local Form 6 (03/16) (page 2) I have claimed an exemption in property pursuant to § 522(b)(3) and state or local law (1) that I or a dependent of mine uses as a residence, claims as a homestead, or acquired as a burial plot, as specified in § 522(p)(1), and (2) that exceeds the amount specified in §522(q)(1). Part IV. Debtor's Signature I certify under penalty of perjury that the information provided in these certifications is true and correct to the best of my knowledge and belief. Executed on _______________ Date ____________________________________ Debtor CERTIFICATE OF SERVICE The undersigned hereby certifies that on _________________________, 20___, a true and correct copy of the Chapter 13 Debtor's Certifications Regarding Domestic Support Obligations and Section 522(q) was served on all creditors and parties in interest listed on the attached mailing list by either first class mail, postage prepaid and properly addressed, or via the CM/ECF system of the United States Bankruptcy Court. ________________________________ Signature American LegalNet, Inc. www.FormsWorkFlow.com