Free UNITED STATES BANKRUPTCY COURT - Louisiana

UNITED STATES BANKRUPTCY COURT MIDDLE DISTRICT OF LOUISIANA In RE: Domestic Support Obligations 1) How many children does debtor-one have and where do the children reside? Does Child Reside If No, Amount of List by age With Debtor-One (Y/N) Monthly Child Support Due _________ _______ $ _________ _________ _______ $ _________ _________ _______ $ _________ _________ _______ $ _________ Case No:

Arrearages $_________ $_________ $_________ $_________

2) List the name, address, and phone number of each person or state agency that debtor-one is ordered and/or pays domestic support to: Name __________________ Name __________________ Name __________________

Address __________________ __________________ Phone __________________

Address __________________ __________________ Phone __________________

Address __________________ __________________ Phone __________________

3) Does Debtor-One owe alimony or maintenance to a spouse, former spouse, or a child's guardian in addition to child support? If yes, provide name, address and phone number of party to whom payment is due: _________________ ____________________________________________________________________________________________ 4) How many children does debtor-two have and where do the children reside? Does Child Reside If No, Amount of List by age With Debtor-One (Y/N) Monthly Child Support Due _________ _______ $ _________ _________ _______ $ _________ _________ _______ $ _________ _________ _______ $ _________

Arrearages $_________ $_________ $_________ $_________

5) List the name, address, and phone number of each person or state agency that debtor-one is ordered and/or pays domestic support to: Name __________________ Name __________________ Name __________________

Address __________________ __________________ Phone __________________

Address __________________ __________________ Phone __________________

Address __________________ __________________ Phone __________________

6) Does Debtor-Two owe alimony or maintenance to a spouse, former spouse, or a child's guardian in addition to child support? If yes, provide name, address and phone number of party to whom payment is due: _________________ ____________________________________________________________________________________________ I declare under penalty of perjury that the information contained above is true and correct. Date: _____________________ Date: _____________________ Signature Signature