UNITED STATES BANKRUPTCY COURT SOUTHERN DISTRICT OF INDIANA In re: [Name of Debtor(s)] Debtor(s) ) ) ) ) ) Case No.: (xx-xxxxx) CERTIFICATION OF ELIGIBILITY FOR CHAPTER 13 DISCHARGE I, the Debtor, having filed a motion for entry of discharge order [motion for hardship discharge] certify that I am eligible for discharge under all applicable bankruptcy laws and rules, or certify that I am eligible for discharge prior to completion of plan payments ("hardship discharge") pursuant to 11 U.S.C. §1328(b), testify under penalty of perjury to the following (complete all sections and provide all required information) and request that the Court enter a discharge. 1. I have completed, after the filing of this case, the Personal Financial Management course required by 11 U.S.C. §1328(g)(1) and have filed the requisite certification (Official Form 23). 2. The provisions of 11 U.S.C. §522(q)(1) are not applicable to this case under 11 U.S.C. §1328(h) and there are no proceedings pending against the Debtor of the kind described in 11 U.S.C. 522(q)(1)(A) or 522 (q)(1)(B). 3. a. (To be completed by all debtors) If I have a domestic support obligation, the name and address of each holder of a domestic support obligation is as follows: [List name(s) with mailing address(es).] b. (If filing a motion for hardship discharge this paragraph can be deleted) Pursuant to 11 U.S.C. §1328(a), if I have a domestic support obligation, all amounts payable under any judicial or administrative order or by statute for domestic support obligations that were due on or before the date upon American LegalNet, Inc. www.FormsWorkFlow.com which this certification was signed, including all payments due under the plan for amounts due before the petition was filed, have been paid. (Only a debtor reporting a Domestic Support Obligation is required to complete paragraphs 4 through 6.) 4. My most recent/current address is: (List address.) 5. The name and address of my most recent/current employer or income source is: (List employer or income source.) 6. The name and address of each creditor holding a claim against me that is not dischargeable under 11 U.S.C. §523(a)(2) or (a)(4), or a claim that was reaffirmed under 11 U.S.C. §524(c), is as follows: (List creditors with mailing addresses.) I declare under the penalties of perjury that this Certification of Eligibility is true and correct. Date: _____________ ____________________________________ Signature of Debtor. (Note: Each debtor must file a separate certification.) American LegalNet, Inc. www.FormsWorkFlow.com