MSSB-DIAS (09/2011) UNITED STATES BANKRUPTCY COURT SOUTHERN DISTRICT OF MISSISSIPPI In re: Case No.: Chapter DECLARATION IN SUPPORT OF MOTION TO IMPOSE THE AUTOMATIC STAY PURSUANT TO 11 U.S.C. § 362(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 the following 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/have not] had any prior case[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. Page 1 of 2 American LegalNet, Inc. www.FormsWorkFlow.com MSSB-DIAS (09/2011) 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) Debtor's Signature Executed on: (date) Joint Debtor's Signature (if applicable) Page 2 of 2 American LegalNet, Inc. www.FormsWorkFlow.com