Debtor'S Affidavit Requesting Discharge Page 4

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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 me a discharge in this case. I further understand
that the court may revoke my discharge if such order of discharge was procured by fraud.
Signature of Debtor:_____________________________
Date: _________________
NOTICE OF OPPORTUNITY TO OBJECT
Any objections to the accuracy of this affidavit must be filed within fourteen (14) days of
the date of service of this Affidavit. If no objection is filed, the Court will consider entering a
discharge order in this case without further notice or hearing.
CERTIFICATE OF SERVICE
I hereby certify that this affidavit was served this ______ day of ____________, 20__,
electronically to those recipients authorized to receive a Notice of Electronic Filing by the Court,
and/or first class mail, postage prepaid to:
Chapter 13 Trustee
All creditors and parties in interest.
Local Bankruptcy Form P
Page Four

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