VTB Form K 0 4 /2018 See Vt. LBR 4002 - 1(a) UNITED STATES BANKRUPTCY COURT DISTRICT OF VERMONT In re: , Chapter Debtor(s). Case # D EBTOR S C ERTIFICATION AND R EQUEST FOR A W AIVER OF THE C REDIT C OUNSELING R EQUIREMENT OF 11 U.S.C. 247 109( h )(1) NO W COME S th e above - name d d ebto r an d states (choose one) : I. Pursuant to 11 U.S.C. 247 109(h)(3) , I a m seekin g a temporar y waive r o f the obligation to comply w ith 247 109(h)(1 ) o f th e Bankruptc y Code . I attes t th e followin g exigen t circumstance s exist and warrant a temporar y waive r o f the credit counseling requirement of 247 109(h)(1): [ describe the exigent circumstances here ] Further, I attest that I requested credit counseling services form an approved nonprofit budget and credit counselin g agency , bu t wa s unabl e t o obtai n th e service s referre d t o i n 247 109(h)(1 ) durin g th e 5 - da y perio d beginnin g o n th e dat e o n whic h I mad e tha t request. OR II. Pursuan t t o 1 1 U.S.C . 247 109(h)(4) , I a m seekin g a permanen t waive r o f the obligation to comply with the credit counseling requirements of 247 109(h)(1 ) o f th e Bankruptc y Code . I attes t thi s permanen t waive r i s warranted because : [c hoos e th e ite m tha t applies - on e ite m must b e chosen ] I am incapacitate d a s tha t ter m i s define d i n 247 109(h)(4 ) o f th e Bankruptc y Code; I am disable d a s tha t ter m i s define d i n 247 109(h)(4 ) o f th e Bankruptc y Code ; or I am i n activ e militar y dut y i n a militar y comba t zone [ specify: ]. AND I wil l fil e a motio n requestin g th e Cour t ente r a n orde r grantin g me a permanen t waiver . I certify under penalty of perjury that the foregoing is true and correct. Debtor name (printed) ignature Debtor address Date of signature American LegalNet, Inc. www.FormsWorkFlow.com