FLNB Local Form 30 (Rev. 04/11) UNITED STATES BANKRUPTCY COURT NORTHERN DISTRICT OF FLORIDA In re: Case No.: Chapter 13 Debtor(s) DEBTOR(S)' ELECTION TO USE A PORTION OF TAX REFUND PURSUANT TO CONFIRMED PLAN TERMS COMES NOW the Debtor(s) by and through the undersigned attorney, and hereby files the Election to Use a Portion of Tax Refund Pursuant to Confirmed Plan Terms, and states as follows: 1. The confirmed plan allows the Debtor(s) to use thirty percent (30%) of a tax refund each year for the first three (3) years in a 36 month term case, plus an additional forty percent (40%) of each year's tax refund for each year thereafter in a 60 month term case. 2. The plan term in this case is 3. This is the Debtor(s)' months. election in this case for the year 4. The Debtor(s) is electing to use $ tax year . of the total tax refund for . The remainder shall be transmitted forthwith to the Chapter 13 Trustee. 5. The Debtor(s) agree that the plan base shall be adjusted by the total amount of the United States Income Tax Refund ($ ) and shall be paid to the Trustee as set forth below: American LegalNet, Inc. www.FormsWorkFlow.com x Portion used ($ ) to be submitted (explain terms of repayment): x Remainder ($ ) to be submitted within ten (10) days from the date of receipt of the refund. 6. This election is being made due to the need for payment of necessary expenses and/or due to the loss of income. RESPECTFULLY SUBMITTED this day of , 2009. Debtor's Attorney CERTIFICATE OF SERVICE I HEREBY certify that a true and accurate copy of the foregoing has been furnished by electronic filing or first class mail to: on the same date as the document was filed electronically as reflected on the Court's docket. American LegalNet, Inc. www.FormsWorkFlow.com