UNITED STATES BANKRUPTCY COURT EASTERN DISTRICT OF MISSOURI In re: DEBTOR NAME, Debtor. ) ) ) ) ) Case No. Chapter CERTIFICATION OF DOMESTIC SUPPORT OBLIGATIONS The undersigned Debtor hereby certifies under penalty of perjury: (check appropriate box). 9 I have paid all amounts due under a domestic support obligation order as provided in 11 U.S.C. §1328(a) or §1228(a), as applicable, as of the date of this certification; I did not have a domestic support obligation when I filed my bankruptcy petition, and I have not been required to pay any such obligation since then. 9 By signing below, I further certify that the information contained in this certification is true and accurate under penalty of perjury and, if required, that I served (mailed) a copy of this document to each person entitled to receive domestic support obligations from me. Those persons are listed below. Dated: _______________ Signed: ________________________________ Debtor's Printed Name: ________________________________ (In a joint debtor case, each debtor must sign and file a separate form.) Domestic Support Recipient(s): Name: Address: ______________________________ ______________________________ ______________________________ ______________________________ ______________________________ ______________________________ Name: Address: 8/2013 American LegalNet, Inc. www.FormsWorkFlow.com