UNITED STATES BANKRUPTCY COURT EASTERN DISTRICT OF WISCONSIN In re _________________________, Debtor Case No._____________ Chapter______________ DEBTOR’S CERTIFICATION FOR FILING CASE WITHOUT CREDIT BRIEFING [Complete one of the following statements.] G I/We, ____________________________________________, the debtor(s) in the above(Printed Name(s) of Debtor and Joint Debtor, if any) styled case hereby certify that on ____________________ I/we attempted to obtain a pre-filing (Date) briefing outlining opportunities available for credit counseling and assisting in related budget analysis from __________________________, but the named agency was unable to provide me (Name of Agency Contacted) with such briefing within five days of the request and before my/our personal circumstances required that the case be filed to avoid financial harm. The circumstances requiring filing before the briefing are as follows: ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ I/We understand that the briefing required by 11 U.S.C. § 109(h) must be completed, and a certificate of the agency providing services and the debt repayment plan, if any, shall be filed with the court within 30 days of filing the petition, except that the court may extend the time for completing the briefing and filing the certificate for no more than an additional 15 days if the debtor(s) file a request stating the reasons for the extension in writing before the expiration of 30 days from the date of filing. - or I/We_____________________________________________, the debtor(s) in the above(Printed Name(s) of Debtor and Joint Debtor, if any) styled case hereby certify that no pre-filing briefing is required because: [Check the appropriate box.] G I am/We are incapacitated or disabled, as defined in 11 U.S.C. § 109(h); or G I am/We are on active military duty in a military combat zone. Signature of Debtor:_______________________ Signature of Joint Debtor:_________________________ Date:_____________________ Date:___________________ American LegalNet, Inc. www.FormsWorkflow.com