UNITED STATES BANKRUPTCY COURT NORTHERN DISTRICT OF MISSISSIPPI In re: Case No.: Chapter DECLARATION IN SUPPORT OF MOTION TO IMPOSE THE AUTOMATIC STAY PURSUANT TO 11 U.S.C. 247362(c)(4) The debtor[s], in support of the Motion to Impose the Automatic Stay, state as follows: 1. [I/We] have personal knowledge of the facts listed in the foregoing situation. 2. [I/We] [am/are] over the age of 18, of sound mind, [am/are] capable of making this Declaration, and [am/are] fully competent to testify to the matters stated herein. 3. [I/We] filed this bankruptcy petition on [date]. 4. [I/We] previously filed bankruptcy cases: [case number], under Chapter [#] on [date] dismissed on [date]. [case number], under Chapter [#] on [date] dismissed on [date]. 5. [I/We] have had no other pending bankruptcy cases in the preceding one-year period. 6. [I/We] have not had any prior cases[s] dismissed in the past year for any of the following reasons: failure to file or amend the petition or other required documents without substantial excuse; failure to provide adequate protection as ordered by the Court; or failure to perform the terms of a plan confirmed by the Court. 7. [I/We] have had a substantial change in [my/our] financial or personal affairs since the dismissal of the last case, and [I/we] believe that this case will: [If a Chapter 7] be concluded with a discharge; or [If a Chapter 11 or 13] result in a confirmed plan that will be fully performed. American LegalNet, Inc. www.FormsWorkFlow.com 8. Those changes are as follows: [Describe in detail]. Check the appropriate box: If executed within the United States, its territories, possessions or commonwealths: [I/We] declare under penalty of perjury that the foregoing is true and correct. If executed outside the United States: [I/We] declare under penalty of perjury under the laws of the United States of America that the foregoing is true and correct. Executed on: (date) Debtor222s Signature Executed on: (date) Joint Debtor222s Signature (if applicable) American LegalNet, Inc. www.FormsWorkFlow.com