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UNITED STATES BANKRUPTCY COURT NORTHERN DISTRICT OF NEW YORK

In re
[Set forth here all names including married, maiden, and trade names used by debtor within last 8 years.]

,

Debtor

Employer's Tax Identification No(s). [if any] Last four digits of Social Security No(s):

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Case No.

Chapter 13

Chapter 13 Debtor(s) Affidavit Demonstrating Entitlement to Discharge

Debtor(s) certifies that the following statements are true and correct: 1. Pursuant to 11 USC § 1328(f) the undersigned have not received a discharge in a prior Chapter 7, 11 or 12 case within four (4) years of the filing of this petition and have not received a discharge in a prior Chapter 13 case within two (2) years of the filing of this petition. All domestic support obligations, if any, due and owing from the undersigned, on or before this date, have been paid in full. Names and addresses of all individuals, if any, to whom the undersigned owe any such ongoing obligations:

2.

3.

The provisions of 11 USC § 522(q)(1) are not applicable to this case pursuant to 11 USC § 1328(h). There are no proceedings pending against the undersigned of the kind described in 11 USC §§ 522(q)(1)(A) or 522(q)(1)(B) pursuant to 11 USC § 1328(h). The undersigned have completed a Debtor Education Program certified by the United States Trustee and have filed form B-23, Debtor's Certification of Completion of Instructional Course Concerning Personal Financial Management, with the Bankruptcy Court Clerk's Office.

4.

5.

Dated: Debtor

Debtor
O:§1328C(10/31/2007)