Domestic Support Obligations Form - United States Bankruptcy Court Middle District Of Louisiana
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1UNITED STATES BANKRUPTCY COURT
MIDDLE DISTRICT OF LOUISIANA
In RE:
Case No:
Domestic Support Obligations
1) How many minor children does debtor-one have and where do the minor children reside?
Does Child Reside
If No, Amount of
List by age
With Debtor-One (Y/N)
Monthly Child Support Due
Arrearages
_________
_______
$ _________
$_________
_________
_______
$ _________
$_________
_________
_______
$ _________
$_________
_________
_______
$ _________
$_________
2) List the name, address, and phone number of the guardian for all minor children listed in item one that do not live
with the debtor. Include any person or state agency that debtor is ordered to pay child support to, as well as any person
who has custo dy of the minor children if other than deb tor, regardless of whether there is a child supp ort court order.
Name
__________________
Name
__________________
Name
__________________
Address __________________
Address __________________
Address __________________
__________________
__________________
__________________
Phone
__________________
Phone
__________________
Phone
__________________
3) Does Debto r-One owe alimon y or maintenance to a spou se, former spouse, or a minor ch ild’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 minor children does debtor-two have and where do the minor 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 the guardian for all minor children listed in item four that do not live
with the debtor. Include any person or state agency that debtor is ordered to pay child support to, as well as any person
who has custo dy of the minor children if other than deb tor, regardless of whether there is a child supp ort court order.
Name
__________________
Name
__________________
Name
__________________
Address __________________
Address __________________
Address __________________
__________________
__________________
__________________
Phone
__________________
Phone
__________________
Phone
__________________
6) Does Debto r-Two owe alimo ny or maintenance to a spo use, former spouse, or a mino r 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 con tained above is true and correct.
Date: _____________________
Signature
Date: _____________________
Signature
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