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Local Form H109h4 (12/15)
Debtor’s Motion for Waiver of Credit Counseling/Debtor Education
[Note: The requirement for credit counseling and debtor education applies to each debtor in a joint case. This
motion is applicable to a single individual.]
An individual debtor is required to obtain credit counseling before filing the bankruptcy petition and to
complete a course concerning personal financial management (debtor education) after filing the bankruptcy
petition. The undersigned requests a waiver from one or both of these requirements based on the following:
Incapacity - the debtor is impaired by reason of mental illness or mental deficiency so that he or
she is incapable of realizing and making rational decisions with respect to his or her financial
responsibility. See 11 U.S.C. § 109(h)(4).
Disability – the debtor is so physically impaired as to be unable, after reasonable effort, to participate
in an in-person, telephone, or Internet briefing. See 11 U.S.C. § 109(h)(4).
Active military duty in a military combat zone.
This request is made on behalf of [name of Debtor 1 or Debtor 2]: ________________________________.
State the facts below to support the waiver request. (This information will be available in the public record on
the Internet – limit the disclosure of any confidential health care information.)
Dated: _____________________________ /s/ __________________________________
[Print name and sign]
Debtor 1 __________________________________________________________________
First Name Middle Name Last Name
Debtor 2 ________________________________________________________________
(Spouse, if filing) First Name Middle Name Last Name
United States Bankruptcy Court - District of Hawaii
Case number ___________________________
(if known)
Fill in this information to identify your case:
