Debtors Statement Of Domestic Support Obligation(s) (Debtor Only)

Penalty for making a false statement: Fine up to $250,000 or imprisonment for up to 5 years or both. 18 U.S.C. 247247 152 and 3571UNITED STATES BANKRUPTCY COURTDISTRICT OF IDAHOIn re,Debtor(s).Case Number: Chapter: DEBTOR222S STATEMENT OF DOMESTIC SUPPORT OBLIGATION(S)If filing jointly, information for joint debtor must be filled out on a separate form. Debtor222s name (enter full name): Does Debtor have a domestic support obligation: yes no. If yes, please fill out the rest of this form. Ifno, do not fill out the rest, but sign where indicated below.Debtor222s employer222s name, address, and phone number: .Name, address and phone number for the holder of the claim of support:.AS OF THE DATE OF FILING THE BANKRUPTCY PETITION:Amount of support obligation: $ per (i.e. month, week, etc.)Term of support obligation: from until .Amount that the domestic support obligation is in arrears: $.Court name and jurisdiction in which order of support was issued:.Court Case No. .Name, address and phone number of the State child support enforcement agency involved in such claim:. I declare under penalty of perjury that the foregoing is true and correct.Signature of DebtorDate American LegalNet, Inc. www.FormsWorkFlow.com