UNITED STATES BANKRUPTCY COURT FOR THE DISTRICT OF SOUTH CAROLINA IN RE: ________________________________, C/A No. __________________ Chapter __ Debtor(s). CERTIFICATION OF INABILITY TO COMPLETE PRE-PETITION CREDIT COUNSELING1 Under penalty of perjury, I certify and attest to the following: I am the/a debtor in the above styled bankruptcy action filed on _______________ (“Petition Date”). Within the one-hundred eighty (180) days prior to the Petition Date, I did not receive the credit counseling required by 11 U.S.C. § 109(h)(1). (Check the box that applies) ________ I am unable to complete the credit counseling required by 11 U.S.C. § 109(h)(1) because of an “incapacity” defined by 11 U.S.C. § 109(h)(4).2 I will submit medical records and/or other appropriate records for private review by the judge, which support my statement that I am incapacitated, within five (5) days of this Certification. ________ I am unable to complete the credit counseling required by 11 U.S.C. § 109(h)(1) because of a “disability” defined by 11 U.S.C. § 109(h)(4).3 I will submit medical records and/or other appropriate records for private review by the judge, which support my statement that I am disabled, within five (5) days of this Certification. ________ I am unable to complete the credit counseling required by 11 U.S.C. § 109(h)(1) because I am a member of the _________________ branch of the United States military on active duty and I am stationed in __________________________, which is located in a military combat zone. 1 All appropriate sections of this Certification must be completed and all requested documents must be timely submitted in order for the request to be considered by the Court. 2 “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. 11 U.S.C. § 109(h)(4). 3 “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 of the required pre-petition credit counseling. 11 U.S.C. § 109(h)(4). American LegalNet, Inc. www.USCourtForms.com I request that the Court order that I am exempt from pre-petition credit counseling pursuant to 11 U.S.C. § 109(h)(4). I understand that a hearing may be necessary on this Certification for exemption from credit counseling if a party objects or a hearing is scheduled by the Court and that I must attend any hearing scheduled or my request may be denied. I SO CERTIFY TO THE TRUTHFULNESS AND ACCURACY OF THE REPRESENTATIONS MADE HEREIN. _______________________________ (Debtor’s Signature) ___________________, 200__ American LegalNet, Inc. www.USCourtForms.com