UNITED STATES BANKRUPTCY COURT NORTHERN DISTRICT OF NEW YORK In re [Set forth here all names including married, maiden, and trade names used by debtor within last 8 years.] ,) ) Debtor Last four digits of Social Security No(s): Employer Tax Identification (EIN) No(s). (if any) ) ) ) ) ) ) ) Case No. Chapter CHAPTER 12 INDIVIDUAL DEBTOR'S CERTIFICATIONS REGARDING DOMESTIC SUPPORT OBLIGATIONS AND SECTIONS 522(q) Part I. Certification Regarding Domestic Support Obligations (check no more than one) Pursuant to 11 U.S.C. Section 1228(a), I (we) certify that: I (we) owed no domestic support obligation when I filed my bankruptcy petition, and I have not been required to pay any such obligations since then. I (we) am or have been required to pay a domestic support obligation. I have paid all such amounts that my chapter 12 plan required me to pay. I have also paid all such amounts that became due between the filing of my bankruptcy petition and today. Part II. If you checked the second box, you must provide the information below. My current address: _________________________________________________________________ My current employer and my employer's address: _________________________________________________________________ Part III. Certification Regarding Section 522(q) (check no more than one) Pursuant to 11 U.S.C. Section 1228(f), I (we) certify that: I (we) have not claimed an exemption pursuant to §522(b)(3) and state law in property that I or a dependent of mine uses as a residence, claims as a homestead, or acquired as a burial plot, as specified in § 522(p)(1) and (2) that exceeds $146,450* in value in the aggregate. I (we) have claimed an exemption pursuant to §522(b)(3) and state law in property that I or a dependent of mine uses as a residence, claims as a homestead, or acquired as a burial plot, as specified in § 522(p)(1) and (2) that exceeds $146,450* in value in the aggregate, but there is no pending proceeding in which I (we) may be found guilty of a American LegalNet, Inc. www.FormsWorkFlow.com O:1228(10/25/2011) felony of a kind described in §522(q)(1)(A) or found liable for a debt of the kind described in §522(q)(1)(B) . I (we) certify under penalty of perjury that the information provided in these certifications is true and correct to the best of my knowledge and belief. Dated: Debtor Debtor *Amount is subject to adjustments on 04/1/13 and every 3 years thereafter with respect to cases commenced on or after the date of adjustment. O:1228(10/25/2011) American LegalNet, Inc. www.FormsWorkFlow.com