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UNITED STATES BANKRUPTCY COURT

NORTHERN DISTRICT OF FLORIDA

In Re:

MOTION FOR DETERMINATION AND WAIVER OF DEBTOR’S DUTY TO

COMPLY WITH THE CREDIT COUNSELING REQUIREMENT

UNDER 11 U.S.C. SECTION 109(h)(4)

In accordance with Section 109(h)(4) of the Bankruptcy Code, I hereby request that the

Court determine that I may be relieved of the credit counseling requirement imposed by

Section 109(h)(4) of the Bankruptcy Code due to an incapacity, disability or because I am

engaged in active military duty in a military combat zone . For the purposes of making this

request under Section 109(h)(4), I understand that "incapacity" means that 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 responsibilities;

and "disability" means that the debtor is so physically impaired as to be unable, after

reasonable effort, to participate in an in-person, telephone, or internet briefing as required by

statute.

My request is based on one of the following (Please check one of the boxes below):

[In the space provided on the next page, please furnish a detailed explanation setting forth the basis for your request.

Attach any documentation that will assist the Court in making a determination. Please do not include any

unnecessary private information such as the names of your minor children or your full Social Security Number

(include only the last four numbers of your Social Security Number). If both the debtor and joint debtor are making a

request under Section 109(h)(4), each debtor should file a separate request with the Court. Please note that this

waiver only applies to the debtor making the request. A joint debtor to whom this waiver does not apply must still

satisfy the credit counseling requirement .]

Debtor(s)

I have an incapacity.

I have a disability.

I am engaged in active military duty in a military combat zone.

Case No.:

Chapter:

FLNB Local Form 18 (Rev. 07/11)

DIVISION

GAINESVILLE