Rev. 1/2004 UNITED STATES BANKRUPTCY COURT EASTERN DISTRICT OF NORTH CAROLINA Division In re: Bankruptcy Case No. Chapter Debtor(s)* APPEARANCE OF CHILD SUPPORT CREDITOR* OR REPRESENTATIVE I certify under penalty of perjury that I am a child support creditor* of the above named debtor, or the authorized representative of such child support creditor, with respect to the child support obligation which is set out below: Name: Organization: Address: Telephone Number: Date Child Support Creditor* or Authorized Representative Summary of Child Support Obligation If Child Support has been assigned: Amount in arrears: Amount of Support which is owed under Assignment: $ $ Amount currently due per week or per month $ Amount owed primary child support creditor (balance not assigned): $ (per week) (Per month) $ *Child support creditor includes both creditor to whom the debtor has a primary obligation to pay child support as well as any entity to whom such support has been assigned, if pursuant to Section 402(a)(26) of the Social Security Act or if such debt has been assigned to the Federal Government or to any State or political subdivision of a state. American LegalNet, Inc. www.FormsWorkFlow.com