Free UNITED STATES BANKRUPTCY COURT - South Dakota

UNITED STATES BANKRUPTCY COURT DISTRICT OF SOUTH DAKOTA In re: JANE ANNE ANONYMOUS, Debtor. STATE OF SOUTH DAKOTA COUNTY OF WASHABAUGH ) ) ss ) ) ) ) ) ) Bankr. No. 08-10000 Chapter 13 DEBTOR'S CERTIFICATION AND REQUEST FOR DISCHARGE

I, Jane Anne Anonymous, the above-named debtor, being duly sworn, state as follows: 1. I am requesting the Court to issue a discharge in this case.

2. I have completed all payments, including any disposable income payments, due under the confirmed plan and any subsequent modifications to the confirmed plan that were approved by the Court. 3. I have completed an instructional course concerning Personal Financial Management and have filed verification of the same with the Court. 4. Domestic Support Obligation. [Check A or B. If B is checked, complete in full B(1) through B(4).] A._____ NO Support Debt. 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 case was filed or any time thereafter. or B._____ Support Debt. I have been required to pay a Domestic Support Obligation, as defined by 11 U.S.C. § 101(14A), either before this bankruptcy case was filed or any time thereafter. I certify that prior to the date of this affidavit I have paid in full any Domestic Support Obligation payments required by a judicial or administrative order or by statute, including amounts due before or since this bankruptcy case was filed, to the extent provided by the confirmed plan and any subsequent modifications thereto. (1) The name and address of each holder of a Domestic Support Obligation

against me are: _____________________________ _____________________________ _____________________________ (2) My current mailing address is: _____________________________ _____________________________ _____________________________

_______________________________ _______________________________ _______________________________

(3) The name and address of my current employer(s) is/are: _____________________________ _______________________________ _____________________________ _____________________________ _______________________________ _______________________________

(4) The following creditor(s) hold a claim that is not discharged under 11 U.S.C. § 523(a)(2) or (a)(4) or a claim that was reaffirmed under 11 U.S.C. § 524(c) [list name and address of each creditor or specify "NONE"]: _____________________________ _______________________________ _____________________________ _____________________________ _______________________________ _______________________________

5. I have not received a discharge in a chapter 7, 11 or 12 bankruptcy case filed within four years prior to the filing of this chapter 13 bankruptcy case. 6. I have not received a discharge in another chapter 13 bankruptcy case filed within two years prior to the filing of this chapter 13 bankruptcy case. 7. I confirm [check A or B]: A. _____ 11 U.S.C. § 522(q)(1) does not apply because I have not claimed a homestead or other exemption specified in 11 U.S.C. § 522(p)(1) in an amount greater than $125,000; or B. _____ Although I have claimed a homestead or other exemption specified in 11 U.S.C. § 522(p)(1) in an amount greater than $125,000, 11 U.S.C. § 522(q)(1)(A)

does not apply because I have not been convicted of a felony, as defined in 18 U.S.C. § 3156, that under the circumstances demonstrate the filing of the case was an abuse of the provisions of Title 11 of the United States Code, and 11 U.S.C. § 522(q)(1)(B) does not apply because neither of us owe a debt arising from: (i) any violation of the federal securities laws, as defined in § 3(a)(47) of the Securities Exchange Act of 1934, any state securities laws, or any regulation or order issued under federal securities laws or state securities laws; (ii) fraud, deceit or manipulation in a fiduciary capacity or in connection with the purchase or sale of any security registered under § 12 or § 15(d) of the Securities Exchange Act of 1934 or under § 6 of the Securities Act of 1933; (iii) any civil remedy under 18 U.S.C. § 1964; or (iv) any criminal act, intentional tort or willful or reckless misconduct that caused serious physical injury or death to another individual in the preceding five years. 8. There is not currently pending any proceeding in which either 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). By signing this affidavit, I declare under penalty of perjury all the statements contained herein and all the information or documents submitted in support thereof are true and accurate and the Court and the case trustee may rely on the truth of each in determining whether to grant me a discharge in this chapter 13 case. The Court may revoke my discharge if any such statements, information, or documents are not true and accurate. Dated: _______________ _______________________________ Jane Anne Anonymous Subscribed and sworn to before me this ______ day of ____________, 20____. (SEAL) _______________________________ Notary Public My commission expires:

See Committee Notes on Following Page

Committee Notes The document must be completed in full, sworn to and signed in front of a Notary Public, and filed with the Court in order to begin the discharge process. Each debtor in a joint case shall file a separate Certification and Request for Discharge. Any question a debtor may have pertaining to the statements or declarations contained in this certification must be directed to the debtor's attorney, not the case trustee or the clerk's office. They cannot provide legal advice to any debtor or debtor's attorney.