IN THE UNITED STATES BANKRUPTCY COURT FOR THE WESTERN DISTRICT OF PENNSYLVANIA In Re: Debtor : : : : : : : : : : : Bankruptcy No. Chapter 13 Movant v. Related to Document No. Respondent(s) DOMESTIC SUPPORT OBLIGATION CERTIFICATION I, the debtor named below, state as follows: I do not have any obligation to pay alimony, maintenance, or support to a spouse, former spouse, child, child's parent, legal guardian, or responsible relative. OR I owe the following obligation(s) for alimony, maintenance, or support: alimony child support other owed to: Name: _______________________________________________________________________ Address: _____________________________________________________________________ Phone: ______________________________________________________________________ I am current OR in arrears on this obligation. I HEREBY CERTIFY under penalties of perjury that the information in this certificate, including any additional sheets provided, is true, correct, and complete as of the date provided below. Signature of Debtor: ____________________________________________________________ Type or Print Name of Debtor: ___________________________________________________ Date Certificate is Signed: _______________________________________________________ Chapter 13 Case Number: _______________________________________________________ PAWB Local Form 21 (07/13) American LegalNet, Inc. www.FormsWorkFlow.com