IN THE UNITED STATES BANKRUPTCY COURT SOUTHERN DISTRICT OF GEORGIA In re Debtor CASE NO. CHAPTER 12 DEBTOR'S CERTIFICATION OF ELIGIBILITY FOR DISCHARGE THIS REQUEST MAY BE GRANTED UNLESS A PARTY IN INTEREST FILES A RESPONSE OR OBJECTION TO THE CONTENT ALLEGED IN THE CERTIFICATION WITHIN TWENTY-ONE (21) DAYS OF SERVICE. The debtor(s)* in the above captioned matter certifies as follows: 1. The debtor certifies that all payments have been completed under the Plan. 2. Certification Concerning Domestic Support Obligations: A. The debtor has not been required by a judicial or administrative order or by statute to pay any domestic support obligation as defined in 11 U.S.C. §101(14A); Or B. The debtor certifies that all amounts payable under any domestic support obligation (required by a judicial or administrative order or by statute), that are due on or before the date of this certification (including amounts due before the petition was filed, but only to the extent provided for by the plan) have been paid. The name of each holder of a domestic support obligation is as follows: * All further references to "debtor" shall include and refer to both of the debtors in a case filed jointly by two individuals, unless any information is noted as specifically applying to only one debtor. Page 1 of 3 American LegalNet, Inc. www.FormsWorkFlow.com GASB-CertDisch12 [Rev. 4/13/16] 3. Certification concerning 11 U.S.C. §1228(f): The debtor certifies that 11 U.S.C. §522(q)(1) is not applicable to the debtor, and there is not pending any proceeding in which the debtor may be found guilty of a felony of the kind described in §522(q)(1)(A) or liable for a debt of the kind described in §522(q)(1)(B). By signing this motion/certification, I/we acknowledge that all of the statements contained herein are true and accurate and that the Court may rely on each of these statements in determining whether to grant me/us a discharge in this Chapter 12 case. The Court may revoke my/our discharge if the statements relied upon herein are proven to be inaccurate. Dated: Debtor Joint Debtor s/ Attorney for Debtor Bar Number Address Phone Email GASB-CertDisch12 [Rev. 4/13/16] Page 2 of 3 American LegalNet, Inc. www.FormsWorkFlow.com CERTIFICATE OF SERVICE I hereby certify that on this date, a true and correct copy of the foregoing Certification of Eligibility for Discharge was served upon the United States Trustee, the trustee, all domestic support obligation recipients, and all parties in interest as follows: by CM/ECF: by First Class Mail, postage prepaid: Other: Dated: s/ Attorney for Debtor GASB-CertDisch12 [Rev. 4/13/16] Page 3 of 3 American LegalNet, Inc. www.FormsWorkFlow.com