American LegalNet, Inc. www.FormsWorkFlow.com Yes No 5. I owe a debt (or there is pending against me a proceeding in which I may be found liable for a debt) due to a civil remedy under section 1964 of Title 18. Yes No 6 . I owe a debt (or there is pending against me a proceeding in which I may be found liable for a debt) due to a criminal act, intentional tort, or willful or reckless misconduct that caused serious physical injury or death to another individual in the preceding 5 years. Yes No 7 . Although I answered YES to one or more of questions 2 through 6, I am entitled to the exemptions I have claimed and I should receive a discharge because the exemptions are reasonably necessary to support me (and my dependent(s), if any). I declare under penalty of perjury that the foregoing is true and correct. Date: Signed: Debtor Printed Name: American LegalNet, Inc. www.FormsWorkFlow.com