FLNB Local Form 13-13 (Rev. 08/11) UNITED STATES BANKRUPTCY COURT NORTHERN DISTRICT OF FLORIDA DIVISION In re: Case No.: Chapter: Debtor(s) PRE CONFIRMATION STATEMENT REGARDING INDIVIDUAL DEBTOR'S DOMESTIC SUPPORT OBLIGATIONS AND FILING OF TAX RETURNS, AS APPLICABLE, PURSUANT TO CODE AND RULE REQUIREMENTS NOTICE IS HEREBY given that A. pursuant to Local Rule support obligations: , the debtor(s) make(s) the following certification(s) as to domestic The joint debtor, if applicable, is not required to pay any amounts under a domestic support obligation; OR All amounts to be paid by the joint debtor 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. Provide the following information: Joint Debtor's Current Address: The debtor is not required to pay any amounts under a domestic support obligation; OR All amounts to be paid by the debtor 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. Provide the following information: Debtor's Current Address Debtor's Employer & Employer's Address: Joint Debtor's Employer & Employer's Address: B. pursuant to 11 U.S.C. § 1325(a)(9), if applicable, the chapter 13 debtor(s) certifies that: The debtor has filed all Federal, State and local tax returns as required by § 1308. The joint debtor, if applicable, has filed all Federal, State and local tax returns as required by § 1308. I/We declare under penalty of perjury that the foregoing is true and correct. Debtor's Signature Date Joint Debtor's Signature Date American LegalNet, Inc. www.FormsWorkFlow.com