Revised 1/25/06 United States Bankruptcy Court Southern District of New York In re _______________________________, Debtor(s) Case No.________________ Chapter ________ REQUEST FOR WAIVER OF DEBTOR’S DUTY TO COMPLY WITH THE CREDIT COUNSELING REQUIREMENT UNDER SECTION 109(h)(4) In accordance with 11 U.S.C. § 109(h)(4), I hereby request that the court determine that I may be relieved of the credit counseling requirement due to an incapacity, a disability or because I am engaged in active military duty in a military combat zone. For the purposes of making this request under section 109(h)(4), I understand that “incapacity means that the debtor is impaired by reason of mental illness or mental deficiency so that he is incapable of realizing and making rational decisions with respect to his financial responsibilities; and disability means that the debtor is so physically impaired as to be unable, after reasonable effort, to participate in an in person, telephone, or Internet briefing” as required by statute. My request is based on one of the following (please check one of the boxes below): ___ I have an incapacity. ___ I have a disability. ___ I am engaged in active military duty in a military combat zone. [In the space provided below, please furnish a detailed explanation setting forth the basis for your request. Attach any documentation that will assist the court in making a determination. Please do not include any private information such as a full, nine-digit social security number or the names of any minor children. If both joint debtors are making a request under section 109(h)(4), each debtor should file a separate request with the court. Please note that this waiver applies only to the debtor making the request. A joint debtor to whom this waiver does not apply must still satisfy the credit counseling requirement.] ____________________________________________________________________________ ____________________________________________________________________________ ___________________________________________________________________________ ____________________________________________________________________________ ____________________________________________________________________________ American LegalNet, Inc. www.FormsWorkflow.com ____________________________________________________________________________ ____________________________________________________________________________ ____________________________________________________________________________ ____________________________________________________________________________ ____________________________________________________________________________ ____________________________________________________________________________ ____________________________________________________________________________ ___________________________________________________________________________ ____________________________________________________________________________ ________________________________ Signature of Attorney Date ___________________________ Signature of Debtor Date ________________________________ Name of Attorney _______________________________ Name of Debtor (if this is a Joint Case) American LegalNet, Inc. www.FormsWorkflow.com United States Bankruptcy Court Southern District of New York In re _______________________________, Debtor(s) Case No.________________ Chapter ________ ORDER – DEBTOR’S REQUEST FOR A WAIVER OF THE DUTY TO COMPLY WITH THE CREDIT COUNSELING REQUIREMENT UNDER 11 U.S.C. § 109(h)(4) IT IS HEREBY ORDERED that the debtor’s motion is granted / denied. Pursuant to 11 U.S.C. § 109(h)(4), the court determines that the debtor, _______________________, is relieved of the duty to comply with the credit counseling requirement. __________________________, New York Date: _________________________ BY THE COURT. ___________________________________ United States Bankruptcy Judge American LegalNet, Inc. www.FormsWorkflow.com