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IN THE UNITED STATES BANKRUPTCY COURT

FOR THE DISTRICT OF ARIZONA

In re:	)	Chapter 13
)
XXX	)	Case No. 4:20-XXXXX-SHG/BMW
XXX	)
)	DECLARATION OF DEBTOR(S)
Debtor(s).	)	REGARDING FINANCIAL HARDSHIP RELATED TO COVID-19
)
)

I/We, [INSERT NAME(S)], hereby declare and state as follows:

1.	I am the Debtor or Joint Debtor in this Chapter 13 bankruptcy case.

2.	I assert that I have experienced a financial hardship related to COVID-19 as follows:

___	I have been diagnosed with COVID-19 or I am experiencing symptom of COVID-19 and I am seeking a medical diagnosis;

___	A member of my household has been diagnosed with COVID-19;

___	I am providing care for a family member or a member of my household who has been diagnosed with COIVD-19;

___	My child or another person in my household for which I have primary caregiving responsibility is unable to attend school or another facility that is closed as a direct result of the COVID-19 public health emergency and such school or facility care is required for me to work;

___	I am unable to reach my place of employment because of a quarantine imposed as a direct result of the COVID-19 public health emergency;

__	I am unable to reach my place of employment because I have been advised by a health care provider to self-quarantine due to concerns related to COVID-1;

___	I was scheduled to commence employment and do not have a job or I am unable to reach the job as a direct result of the COVID-19 public health emergency;

___	I have become the breadwinner or major support for a household because the head of the household has died as a direct result of COVID-19;

___	I had to quit my job as a direct result of COVID-19;

___	My place of employment is closed as a direct result of the COVID-19 public health emergency; or

___	I meet other additional criteria for unemployment assistance under the CAREs Act.

Attached hereto is documentation evidencing AND quantifying my hardship.

I declare that the foregoing statements are true and correct to the best of my knowledge under penalty of perjury.

Dated:	__________________
Debtor

Dated:	__________________
Joint Debtor