Debtor'S Affidavit Requesting Discharge Page 3
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4___ I, ____________________________________, the debtor in the above-styled
(printed name of debtor)
case am required by judicial or administrative order, or by statute, to pay a domestic support
obligation as defined in 11 U.S.C. § 101(14A). (This refers to a debt owed to or recoverable
by a spouse, former spouse or child of the debtor or such child’s parent, legal guardian or
responsible relative or a governmental unit in the nature of alimony, maintenance or
support.) The name and address of each holder of a domestic support obligation follows:
_______________________________
_______________________________
_______________________________
_______________________________
_______________________________
_______________________________
_______________________________
_______________________________
[check the appropriate box.]
___ I hereby certify that all amounts payable under such order or such statute that
are due on or before the date of this affidavit (including amounts due before the
petition was filed, but only to the extent provided for by the plan) have been paid;
or
___ I have executed, and the court has approved, a written waiver of discharge
pursuant to 11 U.S.C. § 1328(a).
My current address is:
_______________________________
_______________________________
_______________________________
The name and address of my most recent/current employer is:
_______________________________
_______________________________
_______________________________
_______________________________
Local Bankruptcy Form P
Page Three
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