Form Number LR 4003-2 D (07/10) UNITED STATES BANKRUPTCY COURT FOR THE NORTHERN DISTRICT OF ALABAMA NORTHERN DIVISION In re: } } } } } Debtor(s) Case No. Chapter DEBTOR'S DECLARATION TO AVOID LIEN PURSUANT TO 11 U.S.C. § 522(f)(2) My name is ______________________________________________. I do hereby certify that I am over the age of nineteen and that, based on my personal knowledge as the owner of ___________________________________________________ (the "Property"), and I incurred a debt or obligation with _______________________________________________ ("Respondent") on or about the day of , . This debt or obligation is secured by (e.g., judicial lien, security interest or other applicable interest) against the Property which was perfected or recorded on _____________ (date) in Book ______ at Page , or Instrument Number ________, ____________ County, __________ (state). [If applicable, insert: Although the Property was pledged to Respondent as collateral, I did not use the proceeds of the loan to acquire the Property.] As of the petition date, the Property has a fair market value of $____________________ based on (e.g., appraisal, tax assessment, opinion of dealer, recent purchase price). I have claimed an exemption in the Property in the amount of $_________ under Alabama Code § . The value of the Respondent's lien is $ . The other liens against the Property are for $ , and for $ , which total $ . DATED: ______________________________________ Debtor(s) STATE OF ALABAMA COUNTY OF ) ) Before me, the undersigned Notary Public, in and for said county and state, did personally appear (Debtor), who is known to me, and after, by me being first duly sworn, and under oath, did depose and declare the foregoing. SWORN TO and SUBSCRIBED before me this the day of ______________, 20____. ______________________________________ Notary Public My commission expires on: _______________ American LegalNet, Inc. www.FormsWorkFlow.com