TXEB Local Form 4004-c (revised 5-11-07) 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 12 or 13 STATEMENT OF DEBTOR REGARDING APPLICABILITY OF 11 U.S.C. §522(q) IN A CHAPTER 12 OR 13 CASE I, penalty of perjury that: (1) , as a debtor in the above-referenced case,1 declare under I G have G have not: tendered all payments to creditors required to be tendered by me under the provisions of the confirmed Chapter (12 or 13) plan in this case; 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; 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; 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; I G do G do not: owe a pre-confirmation debt arising from any civil remedy provided by 18 U.S.C. §1964; 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 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. (2) (3) (4) (5) (6) (7) Date:_____________________ Signature:_________________________ Debtor 1 A separate certification must be submitted for each debtor seeking a discharge in this case. American LegalNet, Inc. www.FormsWorkflow.com