Domestic Support Obligation {LF 3}

LOCAL FORM 3 DOMESTIC SUPPORT OBLIGATION DISCLOSURE This form must be submitted directly to the Trustee within 14 days of filing your bankruptcy schedules. DO NOT FILE this form with the Court. IN THE UNITED STATES BANKRUPTCY COURT FOR THE WESTERN DISTRICT OF OKLAHOMA IN RE: _________________________, Debtor(s). ) ) ) ) ) Case No. __-________-___ Chapter ___ AFFIDAVIT AND DISCLOSURE OF DOMESTIC SUPPORT OBLIGATIONS (Note: A separate form must be submitted to the Trustee for each debtor in a joint case) __________________, Debtor, being first duly sworn under oath, deposes and states: (Print Debtor's Name) (Select One) I do not owe any person or entity a debt defined in 11 U.S.C. § 101(14A) as a "domestic support obligation." I do owe the following person(s) or entity(ies) a debt defined in 11 U.S.C. § 101(14A) as a "domestic support obligation" (attach all supporting documents that establish the terms of a domestic support obligation (i.e. copy of debtor's divorce decree, orders establishing parent- child relationship, and orders establishing or modifying child support)): Name of holder of claim for Domestic Support Obligation Name of service/collection agent (if applicable) Address Telephone Number 1. 2. Name of holder of claim for Domestic Support Obligation Name of service/collection agent (if applicable) American LegalNet, Inc. www.FormsWorkFlow.com Address Telephone Number (Attach additional sheets if necessary) If you owe a domestic support obligation, provide the following additional information. The name and address of my most recent employer(s) is as follows: Employer Name: Employer Address: __________________________ __________________________ __________________________ __________________________ __________________________ __________________________ __________________________ __________________________ s/________________________________________ Debtor Name Employer Name: Employer Address: Dated:_______________________ Sworn to and subscribed before me this ___day of ________________, 20__. [SEAL] __________________________________________ Notary Public American LegalNet, Inc. www.FormsWorkFlow.com