Chapter 11 Individual Debtors Certification Regarding Domestic Support Obligations {O-1129A}

UNITED STATES BANKRUPTCY COURT NORTHERN DISTRICT OF NEW YORK In re [Set forth here all names including married, maiden, and trade used by debtor within last 8 years.] names Debtor Last four digits of Social Security No(s): Employer Tax Identification (EIN) No(s). (if any) ,) ) ) ) ) ) ) ) ) Case No. Chapter 11 CHAPTER 11 INDIVIDUAL DEBTOR'S CERTIFICATION REGARDING DOMESTIC SUPPORT OBLIGATIONS, FINANCIAL MANAGEMENT CERTIFICATE, DISCHARGE ELIGIBILITY AND APPLICABILITY OF SECTION 522(q) Part I. Certification Regarding Domestic Support Obligations (check no more than one) Pursuant to 11 U.S.C. § 1129(a)(14), I (we) certify that: Part II. I (we) owed no domestic support obligations when this bankruptcy petition was filed, and (we) have not been required to pay any such obligations since then. I (we) have been, required to pay a domestic support obligation. All such amounts required to be paid, have been paid. If you checked the second box, you must provide the information below. My current address: _________________________________________________________________ My current employer and employer's address: _________________________________________________________________ Part III. Certification Regarding Section 522(q) (check no more than one) Pursuant to 11 U.S.C. § 1141(d)(5)(C), I (we) certify that: I (we) have not claimed an exemption pursuant to § 522(b)(3) and state law in property that I or a dependent of mine uses as a residence, claims as a homestead, or acquired O:1129A(11/01/2011) American LegalNet, Inc. www.FormsWorkFlow.com as a burial plot, as specified in § 522(p)(1) and (2) that exceeds $146,450* in value in the aggregate. I (we) have claimed an exemption pursuant to § 522(b)(3) and state law in property that I, or a dependent of mine, uses as a residence, claims as a homestead, or acquired as a burial plot, as specified in § 522(p)(1) and (2) that exceeds $146,450* in value in the aggregate, but there is no pending proceeding in which I(we) may be found guilty of a felony of a kind described in 11 USC § 522(q)(1)(A) or found liable for a debt of the kind described in § 522(q)(1)(B). Part IV: Certification Regarding Eligibility to Receive a Discharge Pursuant to 11 U.S.C. § 1141, I (we) certify that one of the following statements applies: I (we) am eligible to receive a discharge because: (all must apply) a) All payments have been completed under the plan; b) § 1141(d)(3) does not apply; c) No order denying discharge has been entered in this case. I (we) are seeking entry of discharge by motion under § 1141(d)(5)(B). I (we) are not eligible for and am not seeking entry of discharge. Part V: Certification Regarding Completion of Financial Management Course I (we) certify that: If 11 U.S.C. § 1141(d)(3) applies, I(we) have completed a course concerning personal financial management and have filed with the Bankruptcy Court Clerk's office, Official Form B23 - Debtors Certification of Completion of Post-petition Instructional Course Concerning Personal Financial Management. 11 U.S.C. § 1141(d)(3) does not apply and I (we) are not required to complete a course concerning personal financial management. I (we) certify under penalty of perjury that the information provided in these certifications is true and correct to the best of my knowledge and belief. Dated: Debtor Debtor *This amount is subject to adjustment on 04/01/13 and every 3 years thereafter with respect to cases commenced on or after the date of adjustment. O:1129A(11/01/2011) American LegalNet, Inc. www.FormsWorkFlow.com