UNITED STATES BANKRUPTCY COURT WESTERN DISTRICT OF TENNESSEE _____________________________________________________________________________________________ In re Case No. Chapter Debtor(s). _____________________________________________________________________________________________ APPEARANCE OF CHILD SUPPORT CREDITOR OR AUTHORIZED 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. CHILD SUPPORT CREDITOR Name: Address: REPRESENTATIVE (if different from creditor) Name: Organization: Address: Telephone Number: Telephone Number: __________________ X________________________________________________ Date 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 owed primary child support creditor (balance not assigned): $_____________________ Please 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). Amount currently due per week or per month on a continuing basis: $__________________ (per week) (per month) Child support creditor includes both the 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 assigned pursuant to section 402(a)(26) of the Social Security Act or assigned to the Federal Government or to any State or political subdivision of the State. See uncodified section 304(g), H.R. 5116, the "Bankruptcy Reform Act of 1994," effective October 22, 1994, which is styled "Appearance Before Court" and provides as follows: "Child support creditors or their representatives shall be permitted to appear and intervene without charge, and without meeting any special local court rule requirement for attorney appearances, in any bankruptcy case or proceeding in any bankruptcy court or district court of the United States if such creditors or representatives file a form in such court that contains information detailing the child support debt, its status, and other characteristics." * American LegalNet, Inc. www.FormsWorkflow.com