UNITED STATES BANKRUPTCY COURT DISTRICT OF OREGON In re ) ) ) ) ) ) ) Case No._________________ Debtor's Certification Regarding Payment of Domestic Support Obligations In a Chapter 12/13 Case, and Statement Re 11 USC §522(q)(1) Applicability [NOTE: DO NOT FILE UNTIL Court Notifies You To Do So!] Debtor(s) The undersigned debtor(s) certify under penalty of perjury that: 1. (Check ONE): a. Since the filing of this case I/we have not been required by judicial or administrative order or by statute to pay any domestic support obligations as defined in 11 USC §101, and that no such obligations were due as of the date of the filing of the petition. b. I/We have paid all domestic support obligations as defined in 11 USC §101 to the obligee that are or were due on or before the date of this certification (with the exception of any amounts due before the petition was filed to the extent that such amount was provided for in the Chapter 12 or 13 Plan, or not required to be paid under §1222(a) or §1322(a)). c. Debtor is not an individual. 2. There IS IS NOT (check ONE) a pending proceeding in which debtor(s) may be found guilty of a felony or liable for a debt of a kind described in 11 USC §522(q)(1). _________ Date _________________________________ Signature of Debtor _________ Date _______________________________ Signature of Joint Debtor If Point 1.b. above was marked, I certify that on ____________ a copy of this document was served on the obligee (i.e., person to whom such payments were due), and on any agency collecting such payments for the obligee. ____________________________________________________ Signature OSB # (if attorney) ____________________________________________________ Print or Type Signer's Name and Phone No. ____________________________________________________ Signer's Address (if Attorney) ____________________________________________________ 525 (12/17/12) American LegalNet, Inc. www.FormsWorkFlow.com