B2830 (Form 2830) ( 04/1 9 ) * Amounts are subject to adjustment on 4/01/ 22 , and every 3 years thereafter with respect to cases commenced on or after the date of adjustment. U N I T ED S T A T E S B A N K R UP T C Y C O U RT District Of In re Case No. Debt o r CHA P TER 13 DEB T CERTIFIC A TIONS R E G A RDING DOMESTIC S U P P ORT OB L IG A TIONS AND S E CTION 522(q) Part I. Certification Regarding Domestic Support Obligations ( c heck no more than one) Pursuant to 11 U.S.C. S ection 1328( a ), I ce r tify that: I owed no domestic suppo r t obligation wh e n I filed my bankrupt c y petition, and I have not b e en r e quired to pay any such obli g ation since then. I am or h a ve be e n requir e d to pay a domestic support obli g ation. I have p a id all such amounts that my chapt e r 13 plan r e quired me to p a y . I have a lso paid all such amounts that bec a me due b e tween the filing of my bankrupt c y petition and toda y . Part II. If y ou che c ked the second bo x , you must provide the information below. My cur r ent add r ess: My cur r ent emplo y er a nd my emplo y er s addr e ss: Part III. Certification Regarding Se c tion 522 ( q) ( che c k no more than one) Pursuant to 11 U.S.C. S ection 1328(h ) , I ce r tify that: I have not c laimed an e x emption pursuant to 247 522(b) ( 3) and state or loc a l law (1) in property that I or a d e pendent of mine uses as a residen c e, cl a ims as a homeste a d, or acqui r ed as a burial plot, as spe c ified in 247 522(p) ( 1), and ( 2) that exce e ds $ 1 7 0,3 50 * in value in the ag g re g ate. I have claimed a n exemption i n prope r ty pursuant to 247 522(b) ( 3) and state or loc a l law (1) that I or a d e pendent of mine uses as a residen c e, cl a ims as a homeste a d, or acqui r ed as a burial plot, as spe c ified in 247 522(p) ( 1), and ( 2) that exce e ds $ 1 7 0,3 50 * in value in the ag g re g ate. American LegalNet, Inc. www.FormsWorkFlow.com B 2830 (Form 2830) (page 2 ) Part IV. Signature I ce r tify under p e nalty of pe r jury that the information provid e d in these ce r tifications is true and c orr e ct to the best of my knowled g e and b e lief. E x ecut e d on Date Debtor American LegalNet, Inc. www.FormsWorkFlow.com