Form 281 (08/06) United States Bankruptcy Court _______________ District Of _______________ In re ______________________________, Debtor(s) Case No. ________________ 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 X_________________________________________________ Child Support Creditor* or Authorized Representative Summary of Child Support Obligation Amount in arrears: If Child Support has been assigned: $ ___________________________ Amount of Support which is owed under assignments: Amount currently due per week or per month: on a continuing basis: $ _______________________ $ ___________________________ (per week) (per month) Amount owed primary child support creditor (balance not assigned): $ _______________________ Attach an itemized statement of account. Do not disclose the name of a minor child. See 11 U.S.C. § 112. If a social security number or a taxpayer identification number is included, set out only the last four digits of the number. Judicial Conference Privacy Policy (09/01). * 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.USCourtForms.com