Free [PFP#592130013] - Texas

BTXN 005 (rev. 1/99)

UNITED STATES BANKRUPTCY COURT NORTHERN DISTRICT OF TEXAS FORT WORTH DIVISION In Re: § § § § § Case No.:

Debtor(s)

APPEARANCE OF CHILD SUPPORT CREDITOR OR REPRESENTATIVE I certify, under penalty of perjury, that I am a child support creditor* of the debtor(s) named below (or the authorized representative of such child support creditor), with respect to the child support obligation set out below. __________________________________
Debtor's Name

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Joint Debtor's Name

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Debtor's Social Security No./Tax ID No.

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Joint Debtor's Social Security No./Tax ID No.

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Debtor's Address

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Joint Debtor's Address

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Signature of Child Support Representative

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Printed Name of Child Support Representative

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Organization

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Telephone Number

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Address

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Date

Summary of Child Support Obligations
Amount in arrears: $ ______________________________________________________________. Amount currently due on a continuing basis: $ _________________________________________. (please note if per week or per month) Complete the following if child support has been assigned. Amount of support which is owed under assignments: $ __________________________________. Amount owed primary child support creditor (balance not assigned): $ ______________________. Attach an itemized statement of account.
* Child support creditor includes both creditor to whom the debtor has a primary obligation to pay child support as well as any entity to whom such support has been assigned, if pursuant to Section 402(a)(26) of the Social Security Act or if such debt has been assigned to the Federal Government or to any State or political subdivision of a State.