TXEB Local Form 4004-d (created 5-11-07) IN THE UNITED STATES BANKRUPTCY COURT FOR THE EASTERN DISTRICT OF TEXAS IN RE: NAME OF DEBTOR Last 4 Digits of Tax ID No. Debtor's Address Debtor § § § § § § § Case No. xx-xxxxx Chapter 12 or 13 CERTIFICATION OF DEBTOR REGARDING STATUS OF DOMESTIC SUPPORT OBLIGATIONS IN A CHAPTER 12 OR 13 CASE I, perjury that: [CHOOSE ONE]: , as a debtor in the above-referenced case,1 declare under penalty of G As of the date of this certification, I have paid all "domestic support obligations," as that term is defined in 11 U.S.C. §101 (14A):2 (a) which were owed by me under any judicial or administrative order, or any statute prior to the commencement of this case (but only to the extent provided for by my confirmed Chapter 13 plan); and (b) which have become due and owing by me under any judicial or administrative order, or any statute since the commencement of this case. G I have owed no domestic support obligations, as that term is defined in 11 U.S.C. §101 (14A), during the pendency of this case. Date:_____________________ Signature:_________________________ Debtor 1 A separate certification must be submitted for each debtor seeking a discharge in this case. 11 U.S.C. §101(14A) provides that: "The term `domestic support obligation' means a debt that accrues before, on, or after the date of the order for relief in a case under this title, including interest that accrues on that debt as provided under applicable nonbankruptcy law notwithstanding any other provision of this title, that is -- (A) owed to or recoverable by -- (i) a spouse, former spouse, or child of the debtor or such child's parent, legal guardian, or responsible relative; or (ii) a governmental unit; (B) in the nature of alimony, maintenance, or support (including assistance provided by a governmental unit) of such spouse, former spouse, or child of the debtor or such child's parent, without regard to whether such debt is expressly so designated; (C) established or subject to establishment before, on, or after the date of the order for relief in a case under this title, by reason of applicable provisions of -- (i) a separation agreement, divorce decree, or property settlement agreement; (ii) an order of a court of record; or (iii) a determination made in accordance with applicable nonbankruptcy law by a governmental unit; and (D) not assigned to a nongovernmental entity, unless that obligation is assigned voluntarily by the spouse, former spouse, child of the debtor, or such child's parent, legal guardian or responsible relative for the purpose of collecting the debt. American LegalNet, Inc. www.FormsWorkflow.com 2