**UNITED STATES BANKRUPTCY COURT**

**EASTERN DISTRICT OF MICHIGAN**

In re:

Chapter 13

> Debtor(s) Case No.

Judge:

**[CERTIFICATION REGARDING DOMESTIC SUPPORT OBLIGATIONS]{.underline}**

(To be filed *separately* by each debtor after completion of all
payments under the plan

in cases filed on or after October 17, 2005)

The Chapter 13 debtor, being first duly sworn, states the following:

**[SECTION I -- TO BE COMPLETED BY EACH DEBTOR]{.underline}**

**Disclosure of Domestic Support Obligations**

During the chapter 13 case, was the debtor required by a judicial or
administrative order, or by statute, to pay a domestic support
obligation as defined in 11 U.S.C. §101(14A)?

Check one: Yes \_\_\_\_\_\_\_\_\_\_\_ No \_\_\_\_\_\_\_\_\_\_

**If yes: Complete Sections II and III below**

**If no: Complete Section III below**

**[SECTION II -- TO BE COMPLETED BY A DEBTOR WHO WAS REQUIRED TO PAY
A]{.underline}**

**[DOMESTIC SUPPORT OBLIGATION DURING THE CHAPTER 13 CASE]{.underline}**

1.  Has the debtor paid all amounts due under the domestic support
    obligation, including amounts due before the petition was filed to
    the extent provided for in the plan?

Check one: Yes \_\_\_\_\_\_\_\_\_\_\_ No \_\_\_\_\_\_\_\_\_\_

2.  List the name and address of each spouse, former spouse or child to
    or for whom alimony, maintenance or support is paid or required to
    be paid (if more space is needed, please attach a separate sheet):

> Name
> \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_
>
> Address
> \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_
>
> City, State and Zip
> \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_
>
> Account Number \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

3.  Has any debt been determined to be non-dischargeable or is any
    action currently pending to determine a debt to be non-dischargeable
    pursuant to:? *(check one):*

  -------------------------------------------- ------------- ------------
  Section                                      Yes           No

  11 U.S.C. Section 523(a)(2)                                

  11 U.S.C. Section 523(a)(4)                                
  -------------------------------------------- ------------- ------------

> If you answered "yes" to any of the above, please identify the
> creditor and the legal basis for the action
>
> Name of Creditor: \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_
> □ 11 USC § 523(a)(2)
>
> Address of Creditor:
> \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_ □ 11 USC §
> 523(a)(4)
>
> City, State and ZIP:
> \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_
>
> If more space is needed, please attach a separate sheet.

4\. Has any debt been reaffirmed pursuant to 11 U.S.C. Section 524(c)?
*(check one):*

Check one: Yes \_\_\_\_\_\_\_\_\_\_ No \_\_\_\_\_\_\_\_\_\_\_

*If yes, please state:*

> Name of Creditor: \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_
>
> Address of Creditor:
> \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_
>
> City, State and ZIP:
> \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_
>
> If more space is needed, please attach a separate sheet.

5\. Debtor's Current Address:

> Name of Debtor's
>
> Current Employer:
>
> Debtor's Current

Employer's Address:

**[SECTION III -- TO BE COMPLETED BY ALL DEBTORS]{.underline}**

**CERTIFICATION**

I declare under penalty of perjury that the foregoing statements are
true and correct to the best of my knowledge, information, and belief.

\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

Debtor's Signature Date