LOCALForm283 UNITED STATES BANKRUPTCY COURT Eastern District Of Wisconsin In re Case No. Debtor CHAPTER13DEBTOR222SCERTIFICATIONSREGARDING(1)DOMESTICSUPPORTOBLIGATIONS,(2)SECTION522(q),AND(3)COMPLETIONOFCHAPTER13PLANPAYMENTSPartI.A.CertificationRegardingDomesticSupportObligations(checknomorethanone)Pursuantto11U.S.C.Section1328(a),Icertifythat:IowednodomesticsupportobligationwhenIfiledmybankruptcypetition,andIhavenotbeenrequiredtopayanysuchobligationsincethen.Iamorhavebeenrequiredtopayadomesticsupportobligation.Ihavepaidallsuchamountsthatmychapter13planrequiredmetopay.Ihavealsopaidallsuchamountsthatbecameduebetweenthefilingofmybankruptcypetitionandtoday.PartI.B.IfyoucheckedthesecondboxinPartI.A.,youmustprovidetheinformationbelow.Mycurrentaddress: Mycurrentemployerandmyemployer222saddress: American LegalNet, Inc. www.FormsWorkFlow.com LOCALForm283 PartII.CertificationRegardingSection522(q)(checknomorethanone)Pursuantto11U.S.C.Section1328(h),Icertifythat:Ihavenotclaimedanexemptionpursuantto247522(b)(3)andstateorlocallaw(1)inpropertythatIoradependentofmineusesasaresidence,claimsasahomestead,oracquiredasaburialplot,asspecifiedin247522(p)(1),and(2)thatexceeds$160,3751invalueintheaggregate.Ihaveclaimedanexemptioninpropertypursuantto247522(b)(3)andstateorlocallaw(1)thatIoradependentofmineusesasaresidence,claimsasahomestead,oracquiredasaburialplot,asspecifiedin247522(p)(1),and(2)thatexceeds$160,3751invalueintheaggregate.PartIII.CertificationRegardingDebtor222sCompletionofAllPaymentsUnderthePlanPursuantto11U.S.C.Section1328(a),Icertifythat:Icompletedallpaymentstothetrusteerequiredbymychapter13plan.Checkoneofthefollowing:Mychapter13plandidnotrequiremetomakeanypaymentsother thanpaymentstothetrustee.Mychapter13planrequiredmetomakepaymentstooneormoreentitiesotherthanthetrustee.Ihavepaidallsuchamountsthatmychapter13planrequiredmetopay.PartIV.Debtor222sSignatureIcertifyunderpenaltyofperjurythattheinformationprovidedinthesecertificationsistrueandcorrecttothebestofmyknowledgeandbelief.Executedon DateDebtor 1Amountsaresubjecttoadjustmenton4/01/19,andevery3yearsthereafterwithrespecttocasescommencedonorafterthedateofadjustment. American LegalNet, Inc. www.FormsWorkFlow.com