UNITED STATES BANKRUPTCY COURT EASTERN DISTRICT OF MICHIGAN In re: Chapter 13 Case No. Judge: Debtor(s) CERTIFICATION REGARDING DOMESTIC SUPPORT OBLIGATIONS (To be filed separately by each debtor after completion of all payments under the plan in cases filed on or after October 17, 2005) The Chapter 13 debtor, being first duly sworn, states the following: SECTION I ­ TO BE COMPLETED BY EACH DEBTOR Disclosure of Domestic Support Obligations During the chapter 13 case, was the debtor required by a judicial or administrative order, or by statute, to pay a domestic support obligation as defined in 11 U.S.C. §101(14A)? Check one: Yes ___________ No __________ If yes: Complete Sections II and III below If no: Complete Section III below ___________________________________________________________________________________ SECTION II ­ TO BE COMPLETED BY A DEBTOR WHO WAS REQUIRED TO PAY A DOMESTIC SUPPORT OBLIGATION DURING THE CHAPTER 13 CASE 1. Has the debtor paid all amounts due under the domestic support obligation, including amounts due before the petition was filed to the extent provided for in the plan? Check one: Yes ___________ No __________ 2. List the name and address of each spouse, former spouse or child to or for whom alimony, maintenance or support is paid or required to be paid (if more space is needed, please attach a separate sheet): Name _______________________________________________________ Address _____________________________________________________ City, State and Zip ____________________________________________ Account Number _________________ 1 American LegalNet, Inc. www.FormsWorkFlow.com 3. Has any debt been determined to be non-dischargeable or is any action currently pending to determine a debt to be non-dischargeable pursuant to:? (check one): Section 11 U.S.C. Section 523(a)(2) 11 U.S.C. Section 523(a)(4) Yes No If you answered "yes" to any of the above, please identify the creditor and the legal basis for the action Name of Creditor: __________________________ G 11 USC § 523(a)(2) Address of Creditor: ___________________________ G 11 USC § 523(a)(4) City, State and ZIP: ___________________________ If more space is needed, please attach a separate sheet. 4. Has any debt been reaffirmed pursuant to 11 U.S.C. Section 524(c)? Check one: If yes, please state: Name of Creditor: __________________________ Address of Creditor: ___________________________ City, State and ZIP: ___________________________ If more space is needed, please attach a separate sheet. 5. Debtor's Current Address: Yes __________ No ___________ Name of Debtor's Current Employer: Debtor's Current Employer's Address: ____________________________________________________________________________________ SECTION III ­ TO BE COMPLETED BY EACH DEBTOR CERTIFICATION I declare under penalty of perjury that the foregoing statements are true and correct to the best of my knowledge, information, and belief. ____________________________________ Debtor's Signature ____________________________________ Date 2 American LegalNet, Inc. www.FormsWorkFlow.com