Local Form 13 (03/09) UNITED STATES BANKRUPTCY COURT NORTHERN DISTRICT OF FLORIDA IN RE: Debtor(s) CASE NUMBER: Chapter ______ CERTIFICATION REGARDING DOMESTIC SUPPORT OBLIGATION PURSUANT TO LOCAL RULE 3015-1 and 4004-1(B) NOTICE IS HEREBY given that, pursuant to [ ] Local Rule 3015-1 or [ ] 4004-1(B), the debtor(s) hereby states as follows (check one of the statements listed below for each debtor): A. Name of Debtor:___________________________ 1. □ That individual debtor is not required to pay any amounts under a domestic support obligation. 2. □ That individual debtor certifies that all amounts to be paid under a domestic support obligation that first became payable after the date of the filing of the petition if the debtor is required by a judicial or administrative order, or by statute, to pay such domestic support obligation, have been paid. If you checked box #2, you must provide the following information: My Current Address: My Current Employer and My Employer’s Address: B. Name of Joint Debtor: ______________________ (if applicable) 1. □ That joint debtor is not required to pay any amounts under a domestic support obligation. 2. □ That joint debtor certifies that all amounts to be paid under a domestic support obligation that first became payable after the date of the filing of the petition if the debtor is required by a judicial or administrative order, or by statute, to pay such domestic support obligation, have been paid. If you checked box #2, you must provide the following information: American LegalNet, Inc. www.FormsWorkFlow.com My Current Address: My Current Employer and My Employer’s Address: I declare under penalty of perjury that the foregoing is true and correct. _______________________________________ Signature of Debtor ________________ Date _______________________________________ Signature of Joint Debtor (if applicable) ________________ Date American LegalNet, Inc. www.FormsWorkFlow.com