UNITED STATES BANKRUPTCY COURT EASTERN DISTRICT OF CALIFORNIA ) IN RE Name of Debtor______________________________ ) ) Name of Joint Debtor_________________________ ) (if applicable) Debtor(s). ) CASE NO. CHAPTER 13 11 U.S.C. § 1328 CERTIFICATE Answers to the questions below must be provided by each debtor to be eligible to receive a discharge. If both debtor and joint debtor complete the form, both must sign the form on the second page. All sections (A ­ D) of the Certificate must be completed. The completed Certificate must be filed with the Clerk of Court and served on the Trustee no later than 30 days after the date of the Notice to Debtor of Completed Plan Payments and of Obligation to File Documents. I declare under penalty of perjury that the information provided in this Certificate is true and correct. A. DOMESTIC SUPPORT OBLIGATIONS [check the appropriate box] Debtor Joint Debtor 1. During the time this bankruptcy case has been pending, I have not been required to pay a domestic support obligation (such as child support, maintenance or alimony) by any order of a court or administrative agency or by any statute. 2. During the time this bankruptcy case has been pending, I have paid all domestic support obligations (such as child support, maintenance or alimony) as required under any order of a court or administrative agency or under any statute. 3. During the time this bankruptcy case has been pending, I have not paid all domestic support obligations, such as child support, maintenance or alimony, as required by an order of a court or administrative agency or by statute. NOTE: Please provide information about your domestic support obligations below. Name and address of each holder of a domestic support obligation, if applicable [add additional sheets if necessary]: Name:__________________________________________________ Address:________________________________________________ ________________________________________________________ Circle one: Above obligation belongs to: Debtor/Joint Debtor. Name:______________________________________________ Address:___________________________________________ ___________________________________________________ Circle one: Above obligation belongs to: Debtor/Joint Debtor. Debtor's current address:_________________________________________________________________________________________ Debtor's employer:______________________________________________________________________________ Joint debtor's current address:__________________________________________________________________ Joint debtor's employer:__________________________________________________________________________ EDC 3-190 (Rev. 2/13/17) Page 1 of 2 American LegalNet, Inc. www.FormsWorkFlow.com B. PRIOR CHAPTER 7, 11, OR 12 BANKRUPTCY DISCHARGE [check the appropriate box] Debtor Joint Debtor 1. I have NOT received a discharge in a Chapter 7, 11 or 12 bankruptcy case filed within four (4) years prior to filing this case. 2. I have received a discharge in a Chapter 7, 11 or 12 case filed within four (4) years prior to filing this case. C. PRIOR CHAPTER 13 BANKRUPTCY DISCHARGE [check the appropriate box] Debtor Joint Debtor 1. I have NOT received a discharge in another Chapter 13 bankruptcy case filed within two (2) years prior to filing this case. 2. I have received a discharge in another Chapter 13 bankruptcy case filed within two (2) years prior to filing this case. D. 11 U.S.C. § 522(q) EXEMPTIONS [check the appropriate box] Debtor Joint Debtor 1. I have NOT claimed exemptions in real property, personal property, or a cooperative used as a residence or claimed as a homestead, or in a burial plot, that exceed the amount stated in 11 U.S.C. § 522 (q) (1). See 11 U.S.C. § 522(p)(1)(A), (B), (C), & (D). 2. I have claimed exemptions in real property, personal property, or a cooperative used as a residence or claimed as a homestead, or in a burial plot, that exceed the amount stated in 11 U.S.C. § 522 (q) (1), but I owe no debts of the type described in 11 U.S.C. § 522 (q). 3. I have claimed exemptions in real property, personal property, or a cooperative used as a residence or claimed as a homestead, or in a burial plot, that exceed the amount stated in 11 U.S.C. § 522 (q) (1), even though I owe debts of the type described in 11 U.S.C. § 522 (q). If this box is checked, I have filed with this Certificate form EDC 3-191, Certificate of Chapter 13 Debtor Regarding 11 U.S.C. § 522 (q) Exemptions. By signing this Certificate, I/we acknowledge that all of the statements contained herein are true and accurate and that the Court may rely on the truth of each of these statements in determining whether to grant me/us a discharge in this case. The Court may revoke my/our discharge if my/our statements are not accurate. Date:__________ Date:__________ EDC 3 190 (Rev. 2/13/17) Page 2 of 2 Signed:____________________ Signed:____________________ Printed Name (Debtor):_________________________ Printed Name (Joint Debtor):____________________ American LegalNet, Inc. www.FormsWorkFlow.com