UNITED STATES BANKRUPTCY COURT for the NORTHERN DISTRICT OF CALIFORNIA IN RE: CHAPTER 13 CASE: __________ DEBTOR(S) STATEMENT RE PENDING PROCEEDINGS UNDER 11 U.S.C. §522(q)(1)(A) AND (B) AND NOTICE THEREOF Debtor(s) STATEMENT BY DEBTOR(S) I declare under penalty of perjury that the foregoing is true and correct: I _____AM/ _______ AM NOT a party to a pending proceeding in which I may be found guilty of a felony of a kind described in §522(q)(1)(A) or found liable for a debt of the kind described in §522(q)(1)(B). Date: ______________ _________________________ Debtor _________________________ Debtor Date: _____________ NOTICE TO ALL PARTIES IN INTEREST NOTICE IS HERBY GIVEN that B.L.R. 9014-1 of the United States Bankruptcy Court for the Northern District of California, prescribes the procedures to be followed and that any objection to the requested relief, or a request for a hearing on the matter, in either case, grounded only on any material inaccuracy in the above certification, must be filed and served upon the initiating party within 21 days of mailing of the notice. A request for a hearing must be accompanied by any declarations or memorandum of law the requesting party wishes to present in support of its position. If there is no timely objection to the requested relief or a request for a hearing, the Court may enter an order granting the relief by default; and the initiating party will give at least 7 days written notice of the hearing to the objecting or requesting party, and to any trustee, in the event an objection or request for hearing is timely made. Date: ________________ _________________________________ Debtor _________________________________ Debtor Date: ________________ American LegalNet, Inc. www.FormsWorkFlow.com