Local Form 13 (Rev. 09/10) UNITED STATES BANKRUPTCY COURT NORTHERN DISTRICT OF FLORIDA Division In re: Case No.: Chapter Debtor(s) CERTIFICATION REGARDING DOMESTIC SUPPORT OBLIGATION PURSUANT TO LOCAL RULE REQUIREMENTS NOTICE IS HEREBY given that, pursuant to Local Rule , 2082-1 B.(4) regarding confirmation debtor(s) hereby states as follows (check one of the statements listed below for each debtor) : the A. Name of Debtor: 1. That the individual debtor is not required to pay any amounts under a domestic support obligation. 2. That the 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 the individual debtor is not required to pay any amounts under a domestic support obligation. American LegalNet, Inc. www.FormsWorkFlow.com 2. That the 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: 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