88 Mon t . LBF 30. STA T E M E N T OF DO M ES TI C S U PP ORT OBLIGATION ( S ). [M o n t . L BR 4002 - 1 ( e)] Na m e o f A tto r n ey O ff i ce M a ili n g A ddress T e l ep h o n e Nu m b er F ac s imil e Nu m b er E - Ma i l A ddress S t a t e Bar I . D. Nu m b er ( A tto r n ey f o r De b to r ( s )) IN THE UNITED STATES BANKRUPTCY COURT FOR THE DISTRICT OF MONTANA IN RE: , , Debtors. Case No. STATEMENT OF DOMESTIC SUPPORT OBLIGATION(S) [ If fili ng j o i n t ly , i n f orma t i on f or b ot h spo u s e s must be pro v i d e d on t h i s f orm] Pu r s ua n t t o M o n t . L BR 4002 - 1 ( e), t h e u n ders i g n ed h ere b y pr o v i des t h i s S t a t e m e n t o f D o m e s t i c S upp o rt O b li ga t i o n (s), as de fi n ed i n 11 U. S . C. 247 101(14 A ). 1. De b t o n a m e ( e n t er f u l l n a m e): 2. D o es De b to r h a v e a d o m e s t i c supp o rt o b li ga t i o n : y es n o . If y e s , p l ea s e f il l o ut t h e r e s t o f t h i s f o r m . If n o , do n o t f il l o ut t h e r e s t , b ut s i gn w h ere i n d i ca t ed b e l o w. 3. De b t o e m p l o y er a n d e m p l o y er s addre ss : 4. Na m e, addre s s , p h o n e n u m b er, e m p l o y er s n a m e, a n d addre s s o f e m p l o y er f o r a n y pers o n resp o n s i b l e w i t h t h e De b to r f o r t h e supp o r t : 5. Na m e, addre s s a n d p h o n e n u m b er f o r t h e h o l der o f t h e c l a i m o f s upp o r t : American LegalNet, Inc. www.FormsWorkFlow.com 89 [ I f t h e De b to r d o es n o t k n o w t h e w h erea b o u t s o f t h e f o r m er s p o u s e, t h i s f act s h o u l d b e a f f i r m a t i v e l y s t a t ed a b o v e, b ut t h e add r e s s f o r t h e supp o rt c o ll ec t i o n age n cy m u s t b e p r o v i ded.] A S OF T HE D A T E OF F ILING OF T HE B A N K R U P T CY P E T I T ION: 1. A m o u n t o f s upp o rt o b li ga t i o n : $ per [ i . e. m o n t h , we e k, e t c.] 2. T erm o f s upp o rt o b li ga t i o n : f r o m u n t i l 3. A m o u n t t h at t h e d o m e s t i c supp o rt o b li ga t i o n i s i n ar r ear s : $ 4. C o urt n a m e a n d j ur i s d i c t i o n i n w h i ch o rder o f s upp o rt was i s s ued: 5. C o urt C as e N o . 6. Na m e a n d addre s s o f S t a t e C h i l d Supp o rt E n f o rce m e n t A ge n cy i n v o l v ed i n s uch c l a i m : I /We d ec l a r e u nder penalty of pe r j u r y t h at t h e fo r egoing is t r ue and co r r ect. Sig n at u r e of Debtor Date Sig n at u r e of Co - Deb t or Date Pe n a l t y f o r m ak i n g a f a l s e s t a t e m e n t : F i n e up t o $250 , 000 o r im pr i s o n m e n t f o r up t o 5 y ears o r b ot h . 18 U. S . C. 247247 152 a n d 3571 American LegalNet, Inc. www.FormsWorkFlow.com