UNITED STATES BANKRUPTCY COURT FOR THE SOUTHERN DISTRICT OF WEST VIRGINIA (revised 11/08) In re , , Debtor(s). Case No. Chapter 13 Adjustment of Debts AFFIDAVIT REQUESTING ENTRY OF HARDSHIP DISCHARGE ORDER *** IN A JO IN T CA S E, EACH DEBTOR M UST CO M PLETE A SEPA RA TE A FFIDA VIT TO BE ELIG IBLE FO R A DISCHA RG E*** The Debtor having filed a motion for entry of a discharge order prior to completion of the plan payments ("hardship discharge"), pursuant to 11 U.S.C. § 1328(b), the undersigned Debtor testifies under penalty of perjury to the following (complete all sections and provide all required information) and requests that the Court enter a discharge. 1. My current address is: 2. The name, address and telephone number of my most recent or current employer is: Employer's Name: Address: Telephone: 3. The following creditor(s) hold a claim that I have reaffirmed under 11 U.S.C. § 524(c), or a claim under 11 U.S.C. § 523(a)(2) or (a)(4) that has been determined to be nondischargeable by separate order: Creditor's Name: Address: Telephone: Creditor's Name: Address: Telephone: Page 1 of 3 American LegalNet, Inc. www.FormsWorkFlow.com Creditor's Name: Address: Telephone: Creditor's Name: Address: Telephone: 4. Completion of Financial Management Course (Debtor Education) Pursuant to 11 U.S.C. § 1328(g)(1) [check the appropriate box] G I have completed a Financial Management Course (Debtor Education) and have previously filed a certificate of completion (Form 23). or G I have completed a Financial Management Course (Debtor Education) and a certificate of completion (Form 23) is attached hereto. or G The Court, by Order entered , has determined that no Financial Management Course (Debtor Education) is required due to incapacity, disability or active duty in a military combat zone. 5. I have not received a discharge in a Chapter 7, 11 or 12 bankruptcy case within four (4) years prior to the filing of this Chapter 13 case. 6. I have not received a discharge in another Chapter 13 bankruptcy case within two (2) years prior to the filing of this Chapter 13 case. 7. I did not have, either at the time of filing this bankruptcy case or at the present time, equity in the type of property described in 11 U.S.C. § 522(p)(1) {generally the debtor's homestead} in excess of the aggregate value specified therein. 8. There is no proceeding pending in which I may be found guilty of a felony of the kind described in 11 U.S.C. § 522(q)(1)(A) or liable for a debt of the kind described in 11 U.S.C.§ 522(q)(1)(B). 9. Certification Regarding Domestic Support Obligations Pursuant to 11 U.S.C. § 1328(a). American LegalNet, Inc. www.FormsWorkFlow.com Page 2 of 3 [check the appropriate box] G I have not been required by a judicial or administrative order or by statute to pay any domestic support obligation as defined by 11 U.S.C. §101(14A) either before this bankruptcy filing or at any time after the filing of this bankruptcy case. or G I am required by judicial or administrative order or by statute to pay a domestic support obligation as defined by 11 U.S.C. §101(14A). {This refers to a debt owed to or recoverable by a spouse, former spouse or child of the debtor or such child's parent, legal guardian or responsible relative or a governmental unit in the nature of alimony, maintenance or support.} If you checked this box, you must list the name, address, and telephone number for each holder of a domestic support obligation in the space provided below. The name, address and telephone number of each holder of a domestic support obligation are: Name: Address: Telephone: Name: Address: Telephone: [check the appropriate box] G I certify that as of the date of this affidavit I have paid all amounts required by a judicial or administrative order or by statute to be paid pursuant to any domestic support obligation as defined by 11 U.S.C. § 101(14A). Amounts due before this bankruptcy filing were paid to the extent provided for by the confirmed plan. or G I have executed, and the Court has approved, a written waiver of discharge pursuant to 11 U.S.C. § 1328(a). I declare under penalty of perjury that all of the above statements are true and correct to the best of my knowledge, information, and belief, and that the Court may rely on the truth of each statement in determining whether to grant a discharge in this Chapter 13 case. The Court may revoke my discharge if the statements relied upon are not accurate. __________________________________________ Signature of Debtor Date: American LegalNet, Inc. www.FormsWorkFlow.com Page 3 of 3