FLNB Local Form 37Ͳ13 (08/11) UNITED STATES BANKRUPTCY COURT NORTHERN DISTRICT OF FLORIDA Gainesville In re: DIVISION Case No.: Chapter 13 Debtor(s) STATEMENT/CERTIFICATION REGARDING REQUIREMENTS FOR DISCHARGE IN A CHAPTER 13 CASE Pursuant to 11 U.S.C. § 1328 and/or Local Rule 4004 1, concerning compliance with the requirements for discharge in a chapter 13 case, the debtor and/or joint debtor, if applicable, hereby state and certify that as to 1. Plan payments: I/We have completed all plan payments; OR I/We have been granted a hardship discharge pursuant to the provisions of 11 U.S.C. § 1328(b). 2. Compliance with 11 U.S.C. § 1328(h) [regarding exemptions]: I/We did not have either at the time of filing this bankruptcy case or at the present time, equity in excess of the dollar amount specified in 11 U.S.C. § 522(q), in the type of property described in 11 U.S.C. § 522(p)(1); OR I/We did have at the time of the filing of this bankruptcy case or do have at the present time, equity in excess of the dollar amount specified in 11 U.S.C. § 522(q), in the type of property described in 11 U.S.C. § 522(p)(1), but a. there has been no conviction in any proceeding and there is not currently a pending proceeding in which the debtor(s) may be found guilty of a felony or liable for a debt of a kind described in 11 U.S.C. § 522(q)(1)(A) [circumstances showing that the filing of this case was an abuse of the provisions of this title], AND b. the debtor(s) is/are not liable for a debt of the kind described in 11 U.S.C. § 522(q)(1)(B) [securities law violations, civil remedies under 18 U.S.C. § 1964; or criminal, intentional, or reckless misconduct that caused death or serious injury to an individual in the past five (5) years]. American LegalNet, Inc. www.FormsWorkFlow.com 3. Post-petition instructional course in personal financial management: I/We have completed a post-petition instructional course in personal financial management and have filed with the court an Official Form 23, Debtor's Certification of Completion of Postpetition Instructional Course Concerning Personal Financial Management and/or the certificate issued by the course provider, for each debtor, if applicable, within the timelines specified in 11 U.S.C. § 1328(g). 4. Domestic Support Obligations (11 U.S.C. 1328(a)): The debtor is not required to pay any amounts under a domestic support obligation; OR All amounts to be paid by the debtor under a domestic support obligation that first became payable after the date of the filing of the petition, if the debtor is required by a judicial or administrative order or by statute to pay such domestic support obligation, have been paid. Provide the following information: The joint debtor, if applicable, is not required to pay any amounts under a domestic support obligation; OR All amounts to be paid by the joint debtor under a domestic support obligation that first became payable after the date of the filing of the petition, if the debtor is required by a judicial or adminis- trative order or by statute to pay such domestic support obligation, have been paid. Provide the following information: Debtor's Current Address: Joint Debtor's Current Address: Debtor's Employer & Employer's Address: Joint Debtor's Employer & Employer's Address: 5. Previous Discharge: The debtor has not received a prior discharge of the kind noted in 11 U.S.C. § 1328(f). The joint debtor, if applicable, has not received a prior discharge of the kind noted in 11 U.S.C. § 1328(f). I/We declare under penalty of perjury that the statements and certifications contained herein are true and correct. Signature of Debtor Date Signature of Joint Debtor, if applicable Date American LegalNet, Inc. www.FormsWorkFlow.com