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Statement Of Debtor Regarding Applicability Template

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TXEB Local Form 4004-c (revised 5-11-07)

IN THE UNITED STATES BANKRUPTCY COURT

FOR THE EASTERN DISTRICT OF TEXAS

IN RE:

Case No. xx-xxxxx

NAME OF DEBTOR

xxx-xx-xxxx

Debtor’s Address

Debtor

Chapter 12 or 13

STATEMENT OF DEBTOR REGARDING APPLICABILITY

OF 11 U.S.C. §522(q) IN A CHAPTER 12 OR 13 CASE

, as a debtor in the above-referenced case, declare under

penalty of perjury that:

I G have G have not: tendered all payments to creditors required to be tendered by me

(1)

under the provisions of the confirmed Chapter (12 or 13) plan in this case;

I G have G have not: been convicted of a felony (as defined in 18 U.S.C. §3156), the

(2)

circumstances of which demonstrate that the filing of this bankruptcy case constituted an

abuse of the provisions of Title 11, United States Code;

I G do G do not: owe a pre-confirmation debt arising from any violation of any federal

(3)

or state securities law or any regulation or order arising from such law;

I G do G do not: owe a pre-confirmation debt arising from fraud, deceit, or

(4)

manipulation in a fiduciary capacity or in connection with the purchase of any registered

security;

I G do G do not: owe a pre-confirmation debt arising from any civil remedy provided

(5)

by 18 U.S.C. §1964;

I G do G do not: owe a pre-confirmation debt arising from any criminal act, intentional

(6)

tort, or willful or reckless misconduct that caused serious physical injury or death to

another individual during the five (5) years preceding the filing of this bankruptcy case;

and

(7)

there is no pending proceeding in which I may be found guilty of a felony or be found

liable for a debt which would alter any of the foregoing declarations.

Date:_____________________

Signature:_________________________

Debtor

A separate certification must be submitted for each debtor seeking a discharge in this case.

Statement Of Debtor Regarding Applicability Template

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