United States Bankruptcy Court Northern District of Texas In re____________________, Debtor Case No.________________ Chapter_________________ DEBTOR’S REQUEST FOR PERMANENT EXEMPTION FROM CREDIT COUNSELING (Complete this form and indicate all situations that apply.) I request that the court order that I am permanently exempt from the requirement to obtain credit counseling pursuant to 11 U.S.C.§ 109(h)(4). I am the debtor in the above referenced bankruptcy case filed on __________________________ and certify that I did not receive credit counseling required by 11 U.S.C. § 109 (h)(1) within the 180 days prior to the filing of this petition. I am unable to complete credit counseling required by 11 U.S.C. § 109(h)(1) because of an “incapacity” defined by 11 U.S.C. § 109(h)(4)1. I will submit medical records and/or appropriate records for court review, which support my statement of incapacity within 5 days of this certification. I am unable to complete credit counseling required by 11 U.S.C. § 109(h)(1) because of a “disability” defined by 11 U.S.C. § 109(h)(4)2. I will submit medical records and/or other appropriate records for court review, which support my statement that I am disabled, within 5 days of this certification. I am unable to complete 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. I declare under penalty of perjury that the foregoing is true and correct. ________________________________________________ __________________________ Signature of Debtor Date 1 “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). 2 “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.FormsWorkflow.com