Statement Of Chapter 13 Debtor Regarding Exemption

United States Bankruptcy Court Northern District of Georgia _________________ Division IN RE: ) ) ) ) Debtor. CASE NO. CHAPTER 13 STATEMENT OF CHAPTER 13 DEBTOR REGARDING 11 U.S.C. § 522(q) EXEMPTION NOTICE: In accordance with 11 U.S.C. § 522(q) and Interim Rule 1007 of the Federal Rules of Bankruptcy Procedure, a debtor who filed a bankruptcy petition with this Court under Chapter 13 and who claims exemptions in property as described in 11 U.S.C. §§ 522(p)(1)(A), (B), (C), and (D) which exceeds the amount set forth in 11 U.S.C. § 522(q) must file this Statement with the Court. The Statement should be filed on or after the date the last payment is made under the plan or, if applicable, on or after the date the debtor files a motion for entry of a hardship discharge under 11 U.S.C. § 1328(b). Failure to timely file this Statement may prevent debtor from receiving a discharge. 1. I elected a homestead exemption in the aggregate amount of $ _____________. PLEASE CHECK ALL BOXES THAT APPLY: Yes No G G 2. I have been convicted (or there is a proceeding currently pending against me in which I may be convicted) of a felony offense punishable by a maximum term of imprisonment of more than one year. G G 3. I owe a debt (or there is pending against me a proceeding in which I may be found liable for a debt) due to a violation of a Federal Securities law (as defined in section 3(a)(47) of the Securities Exchange Act of 1934), including, but not limited to, the Securities Act of 1933 (15 U.S.C. § 77a et seq.); the Securities Exchange Act of 1934 (15 U.S.C. § 78a et seq.); the Sarbanes-Oxley Act of 2002 ((Pub. L. No. 107204, 116 Stat.); the Trust Indenture Act of 1939 (15 U.S.C. § 77aaa et seq.); the Investment Company Act of 1940 (15 U.S.C. § 80a-1 et seq.); the Investment Advisers Act of 1940 (15 U.S.C.A. § 80b-1 et seq.); and the Securities Investor Protection Act of 1970 (15 U.S.C. § 78aaa et seq.); any State securities laws; or any regulation or order issued under Federal securities laws or State securities laws. Page 1 of 2 American LegalNet, Inc. www.FormsWorkFlow.com Yes No G G 4. I owe a debt (or there is pending against me a proceeding in which I may be found liable for a debt) due to fraud, deceit, or manipulation in a fiduciary capacity or in connection with the purchase or sale of a security registered under section 12 or 15(d) of the Securities Exchange Act of 1934 or under section 6 of the Securities Act of 1933. G G 5. I owe a debt (or there is pending against me a proceeding in which I may be found liable for a debt) due to a civil remedy under section 1964 of Title 18. 6. I owe a debt (or there is pending against me a proceeding in which I may be found liable for a debt) due to a criminal act, intentional tort, or willful or reckless misconduct that caused serious physical injury or death to another individual in the preceding 5 years. 7. Although I answered YES to one or more of questions 2 through 6, I am entitled to the exemptions I have claimed and I should receive a discharge because it is reasonably necessary to support me (and my dependent(s), if any). _____________________ Case Number G G G ____________________________ Debtor's Name (Print) ___________________________ Debtor's Signature ___________________________ Joint Debtor's Name (Print) ___________________________ Joint Debtor's Signature ______________________ Date ________________________ Date Statement of Chapter 13 Debtor Regarding 11 U.S.C. § 522(q) Exemption American LegalNet, Inc. www.FormsWorkFlow.com