TXEB Local Form 4004-b (revised 12-1-09 -- change in title only) IN THE UNITED STATES BANKRUPTCY COURT FOR THE EASTERN DISTRICT OF TEXAS IN RE: NAME OF DEBTOR xxx-xx-xxxx Debtor’s Address Debtor § § § § § § § Case No. xx-xxxxx Chapter 11 NOTICE OF PLAN COMPLETION AND §522(q) STATEMENT BY INDIVIDUAL DEBTOR IN A CHAPTER 11 CASE I, declare under penalty of perjury that: , as a debtor in the above-referenced Chapter 11 case,1 (1) I G have G have not: tendered all payments to creditors required to be tendered by me under the provisions of the confirmed Chapter 11 plan in this case; (2) I G have G have not: been convicted of a felony (as defined in 18 U.S.C. §3156), the circumstances of which demonstrate that the filing of this bankruptcy case constituted an abuse of the provisions of Title 11, United States Code; (3) I G do G do not: owe a pre-confirmation debt arising from any violation of any federal or state securities law or any regulation or order arising from such law; (4) I G do G do not: owe a pre-confirmation debt arising from fraud, deceit, or manipulation in a fiduciary capacity or in connection with the purchase of any registered security; (5) I G do G do not: owe a pre-confirmation debt arising from any civil remedy provided by 18 U.S.C. §1964; (6) I G do G do not: owe a pre-confirmation debt arising from any criminal act, intentional tort, or willful or reckless misconduct that caused serious physical injury or death to another individual during the five (5) years preceding the filing of this bankruptcy case; and (7) there is no pending proceeding in which I may be found guilty of a felony or be found liable for a debt which would alter any of the foregoing declarations. Date:_____________________ 1 Signature:_________________________ Debtor A separate certification must be submitted for each debtor seeking a discharge in this case. American LegalNet, Inc. www.FormsWorkFlow.com