**[UNITED STATES BANKRUPTCY COURT]{.smallcaps}**

*for the*

**[NORTHERN DISTRICT OF CALIFORNIA]{.smallcaps}**

+--------------------------------+-------------------------------------+
| **[In Re:]{.smallcaps}**       | **[Chapter 13                       |
|                                | Cas                                 |
| Debtor(s)                      | e]{.smallcaps}****[:]{.smallcaps}** |
|                                |                                     |
|                                | **DEBTOR'S CERTIFICATIONS IN**      |
|                                |                                     |
|                                | **SUPPORT OF DISCHARGE AND**        |
|                                |                                     |
|                                | **NOTICE OF OPPORTUNITY FOR**       |
|                                |                                     |
|                                | **HEARING**                         |
+--------------------------------+-------------------------------------+

I, [(debtor's name)]{.underline}, certify (mark one choice for each
numbered section):

> 1\. \_\_\_\_ I HAVE/\_\_\_\_\_ HAVE NOT completed an instructional
> course concerning personal financial management described in 11 U.S.C.
> §111 and have filed a Certification of Completion of Instructional
> Course Concerning Financial Management.
>
> \_\_\_\_ I HAVE been excused from completing an instructional course
> concerning personal financial management described in 11 U.S.C. §111
> pursuant to \_\_\_\_\_ 11 U.S.C. § 1328 (g)(2) or\_\_\_\_ court order.
>
> 2\. \_\_\_\_ I HAVE NOT been required to pay a domestic support
> obligation as that term is defined in 11 U.S.C. §101(14A) by any order
> of a court or administrative agency or by any statute.
>
> \_\_\_\_ I HAVE/\_\_\_\_ HAVE NOT paid all required domestic support
> obligations as that term is defined in 11 U.S.C. §101(14A) that have
> become due on or before the date of this certification (including
> amounts due before the petition was filed, but only to the extent
> provided for by the plan) under any order of a court or administrative
> agency or under any statute.
>
> 3\. \_\_\_\_ I AM/ \_\_\_\_\_AM NOT a party to a pending proceeding in
> which I may be found guilty of a felony of a kind described in
> §522(q)(1)(A) or found liable for a debt of the kind described in
> §522(q)(1)(B).
>
> 4\. \_\_\_\_ I HAVE/\_\_\_\_ HAVE NOT received a discharge in a
> Chapter 7, 11 or 12 bankruptcy case filed within four (4) years prior
> to filing this Chapter 13 case and I HAVE NOT received a discharge in
> another Chapter 13 bankruptcy case filed within two (2) years prior to
> filing this Chapter 13 case.
>
> 5\. I understand that my discharge may be deferred until I complete
> any required instructional course referred to in paragraph 1 or until
> I am current on any required domestic support obligations referred to
> in paragraph 2.
>
> Declaration Under Penalty of Perjury
>
> I declare under penalty of perjury that the above statements are true
> or correct to the best of my knowledge, information and beliefs.
>
> Date:\_\_\_\_\_\_\_\_\_\_\_\_\_\_
> \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_
>
> Debtor
>
> **NOTICE TO ALL PARTIES IN INTEREST**
>
> **NOTICE IS HERBY GIVEN** that B.L.R. 9014-1 of the United States
> Bankruptcy Court for the Northern District of California, prescribes
> the procedures to be followed and that any objection to the requested
> relief, or a request for a hearing on the matter, in either case,
> grounded only on any material inaccuracy in the above certification,
> must be filed and served upon the initiating party within 20 days of
> mailing of the notice. A request for a hearing must be accompanied by
> any declarations or memorandum of law the requesting party wishes to
> present in support of its position. If there is no timely objection to
> the requested relief or a request for a hearing, the Court may enter
> an order granting the relief by default; and the initiating party will
> give at least 10 days written notice of the hearing to the objecting
> or requesting party, and to any trustee, in the event an objection or
> request for hearing is timely made.
>
> Dated:
> \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_
>
> Debtor