BTXN 005 (rev. 1/99) UNITED STATES BANKRUPTCY COURT NORTHERN DISTRICT OF TEXAS In Re: § § § § § Case No.: Debtor(s) APPEARANCE OF CHILD SUPPORT CREDITOR OR REPRESENTATIVE I certify, under penalty of perjury, that I am a child support creditor* of the debtor(s) named below (or the authorized representative of such child support creditor), with respect to the child support obligation set out below. __________________________________ Debtor's Name __________________________________ Joint Debtor's Name __________________________________ Debtor's Social Security No./Tax ID No. __________________________________ Joint Debtor's Social Security No./Tax ID No. __________________________________ Debtor's Address __________________________________ Joint Debtor's Address __________________________________ Signature of Child Support Representative __________________________________ Printed Name of Child Support Representative __________________________________ Organization __________________________________ Telephone Number __________________________________ Address __________________________________ Date Summary of Child Support Obligations Amount in arrears: $ ______________________________________________________________. Amount currently due on a continuing basis: $ _________________________________________. (please note if per week or per month) Complete the following if child support has been assigned. Amount of support which is owed under assignments: $ __________________________________. Amount owed primary child support creditor (balance not assigned): $ ______________________. Attach an itemized statement of account. * Child support creditor includes both 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 pursuant to Section 402(a)(26) of the Social Security Act or if such debt has been assigned to the Federal Government or to any State or political subdivision of a State. American LegalNet, Inc. www.FormsWorkFlow.com