DOMESTIC SUPPORT OBLIGATION CHECKLIST FILE WITH TRUSTEE ONLY DO NOT FILE WITH THE COURT COMPLETE 1 FORM FOR EACH SUPPORT OBLIGATION Debtor Name(s): _______________________________ Bk Case#: ______________________ Debtor Daytime Phone: ( Evening: ( )_____________________ )__________________ Attorney Name: _________________________________________________________________ Name of Claim Holder: ___________________________________________________________ Address of Claim Holder: _______________________________________________________________________________ Mailing Address City/State Zip Support Type: Spousal Support ________ Child Support ________ Both ________ THE FOLLOWING INFORMATION MUST BE COMPLETED ON EACH SUPPORT OBLIGATION. PLEASE BE SURE TO COMPLETE THIS FORM TO THE BEST OF YOUR ABILITY. Name of Applicable State Agency Where Claim Holder Resides: _____________________________________________________________________________ Payment Address: _____________________________________________________________________________ Mailing Address City/State Zip Account #: ______________________ Monthly Payment Amount: $________ Date Payment Late: _______________ Agency Phone #: __________________________ Monthly Due Date: _________________________ Years Remaining: __________ Are ongoing payments being made to the claim holder by Wage Order? YES ____ NO ____ Is the Debtor currently employed: YES _____ NO ______ If yes, Employer Information: _____________________________________________________________________________ Name Mailing Address City/State Zip American LegalNet, Inc. www.USCourtForms.com