FORM 4002-1B (11/09) This form must be submitted directly to the Trustee within 14 days of filing your bankruptcy schedules. DO NOT FILE this form with the Court. UNITED STATES BANKRUPTCY COURT NORTHERN DISTRICT OF OKLAHOMA IN RE: ____________________________, Debtor(s). AFFIDAVIT AND DISCLOSURE OF DOMESTIC SUPPORT OBLIGATIONS (Note: A separate form must be submitted to the Trustee for each debtor in a joint case) Case No. __________ Chapter ____ _________________________, Debtor, being first duly sworn under oath, deposes and states: (Print Debtor's Name) (Select One) G G I do not owe any person or entity a debt defined in 11 U.S.C. § 101(14A) as a "domestic support obligation." I do owe the following person(s) or entity(ies) a debt defined in 11 U.S.C. § 101(14A) as a "domestic support obligation" (attach all supporting documents that establish the terms of a domestic support obligation (e.g., copy of debtor's divorce decree, orders establishing parentchild relationship, and orders establishing or modifying child support)): 1. Name of holder of claim for domestic support obligation Name of Service/Collection Agent (if applicable) Address Telephone Number(s) 2. Name of holder of claim for domestic support obligation Name of Service/Collection Agent (if applicable) Address Telephone Number(s) (Attach additional sheets, if necessary) American LegalNet, Inc. www.FormsWorkFlow.com FORM 4002-1B (11/09) If you owe a domestic support obligation, provide the following additional information. The name and address of my most recent employer(s) is as follows: Employer Name: Employer Address: __________________________________ __________________________________ __________________________________ __________________________________ __________________________________ __________________________________ __________________________________ __________________________________ Employer Name: Employer Address: Dated: ____________________________ s/ Debtor Sworn to and subscribed before me this ____ day of ___________, 20_____. [SEAL] ____________________________________ Notary Public 2 American LegalNet, Inc. www.FormsWorkFlow.com