UNITED STATES BANKRUPTCY COURT WESTERN DISTRICT OF KENTUCKY IN RE: CASE NO: CHAPTER 13 Debtor(s). CERTIFICATION OF DEBTOR INFORMATION REGARDING REQUEST FOR HARDSHIP DISCHARGE The above-captioned debtor certifies under penalty of perjury that the following are true and correct: 1) 2) All of the requirements of 11 U.S.C. § 1328(b) have been met and the debtor is entitled to a hardship discharge. Pursuant to 11 U.S.C. § 1328(a), all amounts payable for domestic support obligations due on or before the date set forth below (including any amounts due before the filing of the bankruptcy petition to the extent provided for by the plan) have been paid to: Name: Address: (repeat for multiple payees) The debtor's employer and address: Name: Address: 3) 4) 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). The debtor has not received a discharge in a case filed under 7, 11 or 12 of this title during the 4-year period preceding the date of the order for relief under this Chapter, or in a case filed under Chapter 13 of this title during the 2-year period preceding the date of such Order. The debtor has completed an instructional course concerning personal financial management described in 11 U.S.C. § 111 and has either previously filed Official Form 23 so certifying with the Court, or such certification and accompanying documents are being contemporaneously filed herewith. 5) The undersigned requests that a discharge be granted in accordance with 11 U.S.C. § 1328(b). DATE: Debtor Debtor Local Form R American LegalNet, Inc. www.FormsWorkFlow.com