Free Appearance of Child Support Creditor or Representative - Colorado

B 281 (12/94)

United States Bankruptcy Court
District Of Colorado
In re _______________________________ Debtor Case No. _____________ Chapter __________

APPEARANCE OF CHILD SUPPORT CREDITOR* OR REPRESENTATIVE
I certify under penalty of perjury that I am a child support creditor* of the above-named debtor, or the authorized representative of such child support creditor, with respect to the child support obligation which is set out below. Name: Organization: Address: Telephone Number: __________________________ Date X ____________________________________________________ Child Support Creditor* or Authorized Representative

Summary of Child Support Obligation Amount in arrears: $ ___________________________ 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

Amount currently due per week or per month: on a continuing basis: $ ___________________________ (per week) (per month)

* 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.